HomeMy WebLinkAboutCLE201600128 Application 2016-06-03Application for Zoning Clearance
CLE #
4 F i
OFFNtF, USE Old Y
PLEASE REVIEW ALL 3 SHEETS Check # Date: Y) ib
Receipt # IQ 4 701 staff.. RmE t__'
PARCEL INFOR
Tax Map and Parcel:
Parcel Owner:
Parcel Addrvsi
0-0— 02 - DI rG0 Existing
or noor)
PR04ARY CONTACT %'
Who should we calVwrite concer
rn�n
/`ing this project? ,S60 t-
Address : zpt._SY-Ii?6� cx!''r' _ -city 1411601,�" State f 4 zip %?SC)
Omer Phone: (M31%heff Celli Fax # %W )` E-mail
APPLICANT INFORMATION _ _
Check any that apply: _ Change of ownership Change of use Change of name evr business .
Business Name/Type:
Previous Business on this
Describe the proposed business including use, number of
ve eles, and goy ad itional inform Lion that you can pro
1reLmt'dt1 t a .
spaces, number of
:, 1'
*'Phis Clearance will only be valid on tiie parcel for which it is approved. if you change, intensify or move the use to a new location, a new Zoriirig
Clearance will be required.
I hereby certify that I own or have the owner's permission to use the space indicated on this application, 1 also certify that the Information provided
is true and acctirste W the of my knowledge. I have head the conditions of approval, and I mrderstand them, and that I will abide by them,
Signature Printed 6(rr'r
APPROVAL INFORMATION
1>1 Approved as proposed ( ] approved with conditions [ ] Denied
Backflow prevention device and/or current test data needed for this site, Contact ACSA, 977-4511, x 117.
E 1 No physical site inspection has been dome for this clearance, Therefore, it is nor is determination of compliance with the existing
site plan
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date t �4 ( G
Zoning Official 4 Date .. t 6/21bg .,
Other OfBidal Date A/ 11
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-5932 Fax: (434) 972-4I26
Revised 7/1/2o I l Page 2 of 3
Intake to complete the following:
lY/�Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / 0
Will there he food preparation?
If so, give applicant a Health Department form.
3 Zoning review can not begin until we receive approval from Realth
Dept. FAX DATE.
Circle the one that appli
Is parcel on private well �pu@ilartr
ter?
If private well, provide He ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic or kublic sewer
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sim permit_
Permit #
YIN
Will there he any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: /o b b _
Y/N
Permitted as: n!
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:_ _ _ Date:
Notes:
Violations:
Yl(5?
If so, List:
oi3Fers:
IN
If so, List: 'Zoo
'Neel e:
YIL!K
If so, List:
Sl"s:
YIN
If so, List:
��
Clearances:
;SDP's
Revised 7/1=11 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must a =nwany zonuig voca flan (Home Occupation, Zoning Clearance, Zoning
Administrator Ddermina dons orAppeals, Sign Perm, Building Permits) if the application is not the
owner.
1 certify that notice of the application,
[County application name and number]
was provided to the owner of record of Tax Map
[narne(s) of the record owners of the parcel]
and Parcel Number. _ by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to
[Name of the record owner if the record owner is a
person; if the owner of record is an entity, identify the recipient of the record and the recipient's
title or office far that entity]
on
Mailing a copy of the application to ! jn4 jq- . IX
[Name of the record owner if the record owner is a person;
if the owner of record is an entity, identify the recipient of the record and the recipient's title or
ofFiice for that entity]
on __ _ _ to the following address:
Bate
[address; written notice mailed to the owner at t9e last known address of the owner as shown on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Kwx-
T,Ra�-tureof Applicant
-_ �..�.
Print Applicant Name
Date 04lze --
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