HomeMy WebLinkAboutCLE201600190 Application 2016-08-26Application for Zonnqo
Clearance
CLE # f
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFOR ION
Tax Map and Parcel:m
Parcel Owner:
Parcel Address: agg Y 4� City I
(IncludA suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?Cis
Existing Zonin
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State CA Zip
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Address: ;j (. (J 1,1-r_. offs City ( - j �t k State _
Office Phone: l L`4 2� $Cell# lye 3.6 S Fax # E-mail
APPLICANT INFORM ION
Check any that apply: V Change of ownership _. GAanjee of use
Business Name/Type:
Zip .f1g
of name New business
r 1 7i oG k
Previous Business on this site 2 2 �� L L�
Describe the proposed business including use, number of employees, numbershifts, available parking s aces, number of
ve�jLSlesh and any additional information that you can provide: �� ` A 4Ar,
*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 accu e y wled a read the conditions of approval, and I understand them, and that I will abide by them.
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Signatur Printed C�o�� - ���(� - S
APPROVAL INFORMATION
Approved as proposed [ j Approved with conditions [ ] Denied
] Backflow 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
Zoning Official
Other Official
\ r �,
Date C.
e� f Date.i
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
C/ ,
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Is l
Is u LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y J
Wil ere 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 public water?
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 _
Is parcel on septic o ublic sew r?
Y I
X')
Wil ou be putting up a new sign of any kind? If so, obtain proper J
Sign permit.
Permit #
Y oWie 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: 14 010
& I N ] p
Permitted as: _mil r�r�iq 1 0
Under Section: 2 9, 1 1
Supplementary regulations section:
Parking formula-
Z5 Ij
Required spaces: </
YYI Q
items o be verified in the field:
Inspector•
Notes:
Date:
Violations:
YIX)
If so, tst:
Proff, s:
YI0
If so, List:
Variance:
&IN
If so, List:
SP's:
®IN
If so, List:
Clearances:
SDP's
- V3
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 p f [k� qr LLC
i ni �&— fcL , } ounty application name and number]
was provided t 11..44 l.l,. the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel ber �0M� M' GJ _ _ Q U by delivering a copy of the application in the
manner " entified 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 for that entity]
on
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 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].
Sign ure of Applicant
Print Applicant Name
s-rtI (-Z-9 I
Date