HomeMy WebLinkAboutCLE201600137 Application 2016-06-10Application for Toning Clearance
CLF'# _ V0 _ V ` ---_--
OFFICE O Y lei
PLEASE REVIEW ALL 3 SHEETS Check#
r I Readpt # _ /�CJ%Vn staff: 114
PARCEL INFOR
Tax Map and Parcel:
Pored
r
Existing Zoni
Pored Address:- in t� 1�4Dr. City 1�state Zip 11
(include suite & floor)
PRIMARY CONTACT c a
Who should we call/write concerning this project? f J
Address : City r state --Azlp�m
�1oS
Ofilee Phone: VS -)Cell J Fax # E-mail
APPLICANT INFORMATION
Chi art tlta# apply; Cb"ge of ownership Change of use Change of same LIJNew business
Business Nametrype: y, l
Previous Business on this siteen
Describe the proposed business including use, number ofemployees, number of shifts, avalltabje parking s sera, number of
vehicles, and any additional information that you can provide. m
*This Clearance will only be valid on the parcel for which it is approved, If you change, intensify or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that I own or have the owner's pemrission to use the space indite an this application, I also cert4 that the information provided
is true and accurate to�w best of my knowledge. I have
%read the conditions of approval, and I undeftd them, and thJa�t I will abideby
signature 6 Printed v .� T l.v� G-A �11
APPROVAL INFORMATION
tPq Approved as proposed L j Approved with conditions [ ] Denied
[ ] BacUow prevention device and/or current test dxta needed for this site. Contact ACSA, 977-4511, x117.
[ 3 No physical site inspection has been done for this clearance. Therefore, it is not a detmmination of compliance with the existing
site plan.
[ ] This site complies with the site plan as ofthis date.
Notes:
Building Official
Zoning USicial
Other Official
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5932 Fax: (434) 9724126
Revised 11/112015 Page 2 of 3
Intake to complete the following:
YIN
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
EngineWs Report (CER) packet.
Y I
Will ere be food potion?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE _
Circle the one that applies
Is parcel on private well or biro orate
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that appli
Is parcel on septic a ublic sewer?
YAD
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
YIN
Will there be 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
! N / /p
Permitted as: r
Under Section: Z- .
Supplementary regulations section:
Parking formula: I/ j 1
Required spaces:
YIN
Items to be verified in the field:
Inspector: Date.
Vlolrttlrrns:
YI
If so, ist:
Profh
YI
If so, at:
Vsri" e•
YI
If so, List:
SP's:
YIN
If so, List:
Clearances.
SDP's
Revised 1 IAMB Page 3 bf 3
z):
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO TBE LANDOWNER
This, jom ~ arempwWnLv *P&Gdow (How U=padM, Zoning ckfflwwe� Z0fiiig
AdnWbtator Ddambadm or Appeak, Sign Perm ts, Berg Perm&) f the apocal on ft net the
owner.
I certify tbat notice of the application,
[County application name and nurnber)
was provided to
C ��,1� _._ L� _�, the owe of record of Tax Map
[name(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 reciplent of the record and the recipient's
title or office ib r that entity]
on
EMT
Mailing 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 for that etrdW
on to the fallowing address:
Date'
[address, written notice mailed to the owner at the last known address of the owner as slim one
the current real estate tax assessment books or current real estate tax assessment records satires
this requirement].
//"," " 1,lxl-�dl
Signature of Applicant
Print Applicant Name
�1�fl&
Date