HomeMy WebLinkAboutCLE201600212 Application 2016-09-22Application for Zonin Clearance"`'
CLE #
Yr
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # e MCP Date:
Receipt # _�� �. Staff:
PARCEL INFORMATION
Tax Map and Parcel: Q ` dQ Existing Zoning,
Parcel Owner: ' r LPA A) �
Parcel Address: O 0 35' 5't, City C)7 A-R u MCI -State J4 Zip ZZ o
_
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Lf _i �d22 2
Address: i, L 1 Jl �f W ) 7 A F_ City L,Ej6 11 State P*-) C Zip�X7/,1 L
Office Phone: Z Cell #q )9 6 Q19r02-1 Fax # Gi LUti !e 17 mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:LF Z A
Previous Business on this site 2 Dl,# 1 v
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide: �
*`Phis 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 Lmowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature t Printed__ L4 1 -rf* 1
APPROVAL INFORMATION
Approved as proposed [ ] 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 Date Q
Zoning Official Date
Other Official Date
County of Albdmarle Department of Community Development ,
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
I]1
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
Y/A
Is us n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet,
YI
ll e 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 ater?
If private well, provide He partment form.
Zoning review can not begin until we receive approval froze, Health
Dept. FAX DATE
Circle the one that appl'
Is parcel on septic or blic s ?
Y/N
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 followianLY:
Reviewer to complete the following:
'Square footage of Use: '--0 ''
;) l N f
Permitted as: = � f
Under Section: �� . - -Plk., C.. D-b
Supplementary regulations section:
Parking formula: ?�
Required spaces:
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
Y /
If so, ist:
Proffers:
N
If so, List:
Vari ce:
Y/
If so, List:
Spas:
Y/N
If so, List:
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 or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
QHand 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:
7 2- 0 CIS ce. �%5�� }� _Cep 4 o 0
M 1,
[address; written notice mailed to the owner at the last known address of the owner as shown on Lf
the current real estate tax assessment books or current real estate tax assessment records satisfies a i?
this requirement].
Signature of Applicant
Print Applicant Name
91 a41b
Date
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