HomeMy WebLinkAboutCLE201600150 Application 2016-07-14Appucatlon for on -in Clear nee _
CLE # �016Cr, 150
0"I u
PLEASE REVMW ALL 3 SHEETS Check # Q date: - 6
Receipt # Staff:
PARCEL INFORMATION y
Tax Map and Parcel: - Existing Zonin COMICYC01 (t
Parcel Owner: S 8 [ o f r % 1 1 i
Parcel Address: S City .,, I I Ie State �P C !1l
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? rl` .
Address: i City�f i State AZip
ORIce Phone: I — -loCen # faxx # E-mail
APPLICANT INFORMATION
Cheek any that apply. Change of ownership Change of use Change ofy�name
.� ,o New 1business
Business Natnarrype: � j�l"�
Previous Business on this site -a.
Describe the proposed business including use, number of empla numbe ofshifts, avai to a spaces, number of
clew, a d ny additional information that you can provide: l
*This Clearance will only be valid an the parcel for which it to approved. If you change, intensity or move the use to a new location, a new �nniitg
Clearance will be required.
I hereby certify that I own or have the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and accurate to
the. bed of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
signature 1. Printed ^'h l � r'-f
APPROVAL INFORMATION
Approved as proposed j j Approved with conditions [ j Denied
[ ] Backtlow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, x117.
[ ] No physical site inspection has been done for this clearance, Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes:
Building Official Date -1
Zoning Official/ Date "
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-5832 Fax: (434) 472-4126
Revised 11/1/2015 Page 2 of 3
I-C)
UNA
Intake to complete the following:
Y
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wil be food preparation?
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 , tah�wateIf private well, provide H@aith form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that appli
Is parcel on septic or ublic sewe
Yl0
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y / Wil erI`ifi e 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:
�IN
Permitted as. ---- _--�
Under Section
Suppler ritary regulations section:
Parking formula: /
Required spaces:
YI
Items to be verified in the field:
Inspector - Date:
Notes.
Violations:
YI0
If so, List:
Pro
YI
If 'st:
Variance:
Y/ T
If so, .
SP"s:
Y/(
[f so, rst;
Clearances:
SDP's
Revised I I 2015 Page 3 of 3
CERTIFICATION TEAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form mast accompwv zonft app&�Woju (Some oacrepaaieu, Zonkw near mm zen&g
Adnimkbawr Daermbdiaxs orAppeufs, Sqx Perm BulAft Perms) iyae appffcown is aw the
os4"er:
I certify that notice of the application,1�
ur[L unty application name and n er]
was provided to ` NLZ f rd of Tax Map
[nam ) of the record owners of the parcel]
and Marcel Number r 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 ifthe 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 entity]
on
Mailing a copy of the application to C�u� '� V 5 N t l _
[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 entity)
oni ��_ �� C`I �C7 fit,p fallowing address:
Date'
l�Y�t��C 1�� 1,0�1'��r��t. ti�� �iv��� �r ,C r1 �►��le V~�- �a°I I1
[address; written notice mailed to the oWna at the last known address of the owner as shown on
the Current real estate tax assessinerYt looks or current real estate tax assessment records satisfies
thisrequiremeM]. %rd (rvv -to PrTcrN nunoqcrcr) {O/Slim
SignaM of Appl cant
/, ke,r ne-�
! r
Print Applicant Name-
_�.al ic2
Date;
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