HomeMy WebLinkAboutCLE201600227 Application 2016-10-05Application for Zoning Clearance °�
CLE # offAe - 0a `7
OFFICE USE ONLY 3 1U
PLEASE REVIEW ALL 3 SHEETS Check # ��-, Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: Ste 3-61 Existing Zonin
Parcelowner: A/OTCh",I GG C
Parcel mod ; 5376 %H.eEe�NDICH LO o!yF1 City 1?20ZC1 State V-4 ZipXg32
(include suite or floor) 0 G
PRIMARY CONTACT
Who should we call/write concerning this project? W 64'
Address. _3IV Vlea41-- JX _ City AUXI Il,"A9 State VA Zip 721�6
Office Phone: `Le Z QQ 7 L-4 Cell # Fax # E-man ch e y S a r,'s. rule �qm�,r ear
r
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: C fJX )1,r d f C4 /N C 44dl CyjAlr&IA,4 ' Q6eV1 C e_( G LC
Previous Business on this site
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, an y additional information that you can provide: Xe? EM
,p/. don CaAG�/n/C �Ma laG!NJ
tEeVf C
*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 beg of m knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature �—�—h� �/ Printed AAM T I?WIC _
APPROVAL INFORMATION
`Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Bacltflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xi 17.
[ ] 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�c//(���, _
Zoning Official Date A � 2-
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 11/02/2015 Page 2 of 3
Intake to complete the following:
YIN
Is use in Ll, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/ T�
Will there 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 oril
lic waIf private well, provide Heapart¢ form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that a
Is parcel on septic public sew
Y N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: �sy
,0IN
Permitted as: L) 1`�I �- B
Under Section:. -2
Supplementary regulations section:
Parking formula:
Required spaces:
YI
Items to be verified in the field:
If so, obtain proper
//�� Inspector : Date:
Y G � Notes:
Willll ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
vio oils:
YI
If so, List:
Proffers:
IN
If so, List:
r, .7
Varu'llkce:
YI' V
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
�013 - 2y
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]
MICHEUe EPROUSE
[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
F57Hand delivering a copy of the application to SPe9q (! 61070> U-C
[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 0C 1613 0 3 2 0/0
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].
Signature of Applicant
Print Applicant Name
Date