HomeMy WebLinkAboutCLE201600177 Application 2016-09-29Application for Zonin Clearance
CLE # WIPA F.
OFFICE SE O Y
PLEASE REVIEW ALL 3 SHEETS Check # 4CDate: 7
Receipt # 4 (RiStafi
PARCEL INFORMATION Olt by — o I -Do — 10600
Tax Map and Parcel: ol — 1 Existing Zoning C
Parcel Owner: WES,-) Z431' t : LO—
� D ww o lts cn Alm- 01i_. loci iota
Parcel Address;- city ___� AQ.tfi'f'F��[IIi�State
(include suite or floor)
PRIMARY CONTACT �} J
Who should we call/write concerning this project?R � i � � 2� 1 �� Lk-14 VA 1413 pm EJ
Address: 5as oi1J0lis l v il)u' U" taotCity 0011—L?-, State zip a'Aq {j
Office Phone: ib WlS CCU # Fax # A`l�)-109 [ E-mail home,�d�oJ�hlax►C�ho�Ylz�S►n
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: �Q40S _ So LI}' DNL
Previous Business on this site i�Ag�,�%Uuip
Describe the proposed business including use, number of employees, number of shifts, available arking spaces, number of
vehicles, and any additional information that you can peovide: l d
be 6 e kga ct
'This Clearance will only be valid on the parcel for which it is approved. If you change, intensify or move the use to i new lollatick, 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"bestofowledge.1 have read the conditions of approval, and I understand them, and that 1 will abide by them.
Signature Printed__XSA ►i,l k 4-,i 14✓l,
APP VAL INFORMATION
[ pproved as proposed [ ] Approved with conditions [ ] Denied
[ J Backtlow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x 117.
[ ] 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 10 � C.
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 9724126
com
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Reviewer to complete the following:
Y /�N Square footage of Use: 100
Is use m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. I (Y yl N
A Pbrmitted as: k1
Y jj�A
Wil N� ere be food preparation? Under Section: � _ � Cpl
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well o ublic wate
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 applies
Is parcel on septic c sewer? a
Parking formula:
�u
Required spaces:
Y/
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit,
Permit # Inspector
;N
dill there be any new construction or renovations?
If so, obt t
Permit ' per
Zoning to complete the following:
Notes:
verified in the field:
Date:
Violations:
Y/N
If so, List:
Proffers:
YIN
If so, List:
Variance:
Y/N
If so, List:
SP's;
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of
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,
[County application name and number]
was provided to R+OsQ5 aixoe �o up, the owner of record of Tax Map
[name(s) of the record owners of the parcel]
C) Irdf) 0 - D1-CJd -- 10600
and Parcel Number D'716 0 - 01- DO [ b aOp by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to �v eo E4 Q-
[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].
5ignatu of Applicant
H/
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Print Applicant Name
At rl Asf (1 2-016
Date
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