HomeMy WebLinkAboutCLE201600164 Application 2016-08-08Application for Zoning Clearance
CLE # ,:Z,iLD —MJ [CA4
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OFFICE rE ON
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFO TON /��l
Tax Map and Parcel:— M 03 s 00— 60 . ?) • Existing Zonin 1 JQ
Parcel Owner: 5 f F—vit TAAk P
Parcel Address: SAGA geaKoAk City C 'e/[L-LF_ State VA Zipaafo
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? ! p
Address : 30'�lp� �� �IL City d .) t � V
tz State A Zip`a -e
Office Phone: t a C� — Cell # Fax # E-mail 1
APPLICANT INFO TION
Check any that apply: Change of ownership Change of use Change of name JUNew business
Business Name/Type: PAY5 IC4(— "TWt 2 AP Y
Previous Business on this site C g( AJ C . r-5 a Y W Oa il- LLC
Describe the proposed business including use, number of employees number of shifts, availabl arking spaces, number of
vehicles, and any additional information tha ou can provide: 51 .CRfr r%Z1�1� �
*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 permission to use the space indicated on this application, I also certify that the information provided
is true and accurate to the best of my knowledge, I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPROVAL NF ATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backllow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, 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 r- Date
Zoning Official Date2��
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
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Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
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Will Pere 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 o uPer?
If private well, provide He artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or blic se r�
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Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
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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: Ia. G 0
IN
rnitted as: _ -O1 Ce—
Under Section: Z-7.2
Supplementary regulations section:
Parking formula: �j
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Required spaces:
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Items to be verified in the field:
Inspector • Date:
Notes:
Viola ions:
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If so, ist:
Proffers:
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If so"List:
Vari e:
Y IIU
If so, List:
SP's}
-
Y /,:,�,
If so, Est:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
Administrator Determinations orAppeals, Sign Permits, Building Permits) if the application is not the
owner.
1 certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
the owner of record of Tax Map
and Parcel Number U l t Vd- 03���_� CJJP D by delivering a copy of the application in the
manner identified below:
x 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 for that entity]
on -21 f f L,-20 tk
Date
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 entity]
on
Date
to the following address:
[address; written notice mailed to the owner at the Iast 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].
41
Signature of Applicant
Print Applicant Name
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Date