HomeMy WebLinkAboutCLE201600218 Application 2016-10-05. pka far o niClearance
!lei
ICT' USE ON
(PLEASE REVM�V ALL 3 U=1 ETS Cheep # B&O Date: 2
Receivt # !F0 Staff. -
FARCE,
L INFOWWA 'I
Tax Map and Parser: i�Ln I:xisfing zoni€nx- . co _
Parcel Owner.• FP
Parcel Addren; U z- Ykcity. PACs to
(include suite or floor)
PRIMARY CONTA
Who Should rie calii/write concerning this project?
Address /tteuiA !q City; eA y, z&zt
Office Paoue: i� (/lt0 ' -7 Ml # % '7r,,11 Pax # ib T-ZS OIAak �
APPLICANT INF' 0. a
Chee!c any 3hat apprly; _- Change of ow=r. lrifr Ch riga of use Cb nge of name l'ew b-asinass
Business Name/Type. e -
Previous Business on this site
Describe the proposed basiness including use, number of emplo , number of lhft, a ailable pa If
n s aces, ou rAf
vehicles, and any additional Information that you can provide;3�+ ;3®
"This Clearance wail only be valid an tho parcel for which it is riffuaved. If you change, imensify or move the use to a new location, a new Zoning
Clearance 4'ili be required.
I hereby certify that I own or have the owner's permission to use the space indicated an this application. I also certify that the information provided
is true and the b of my o edge. I have read the conditions of approval, and understand/them. and that I will abide by them.
Signature Primed
A F00VAL Wrl 0RTI0N
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backfiow 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.
C )This site complies with the site plan as of this date.
Notes:
Building Official Date
Zoning Official bite
Other OffSck Date
County of Alban firle Department of Commuui#y neveloprsrerrt
401 McIntire RoaJ Charlottwvllie, VA 22902 Vol= (434, 296-5 2 Pax: (434) 972-4325
Revised 11/1/2015 page 2 of 3
Intake to complete the following:
Y 4
Is us in LI, 0 or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wi 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 BATE
Circle the one that applies
Is parcel on private well pnrblic watee
If private well, provide Fi ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app "
.is parcel on septic o public sewer')
VN
l you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
N ill there be any new construction or renovations?
If so, obtain the proper Permit,
Permit #
&icing to Complete the rollutyi=
Reviewer to completz the following:
eul
Square footage of Use: :30 _
'; I (U
i�ermiittted as: .6
Under Section: —�-i� �4-n I
Supplementary regulations section:
inspector ' Rate:
Notes:
Vi r, ns:
Y .N
If st.
P c
Y k.N
If so, ist:
Va
YIN
if so, t:
Sl?"
YIN
If ist:
Cie$ maces:
SLP's
Revised 11/1/20I5 Page 3 of 3
APPLICATION HAS BEEN PROVIDED TO THE LANDOWITER
This form Ymn aecwpW zoning appil w1 ons (Rome 0=,pa aam, Zoning aearrance, zoning
Admiidstra wr Defame bdions or Appeals, Ska Permits, Bafl&Rg Permits) if the applfaafta is not the
owner,
I certify that notice of the application,
[Couhly application name and number]
was provided to LV04k, the owner of record of Tax Map
[name(s) of the record owners oftheparcel]
and Parcel Number NL UV _ n - UD ' �J by delivering a copy of the application in the
m:an7ldentified below:
Hand delivering a copy of the applicatton to ��.1l1
ame of the record owner if the record owner � is a
person; ifthe er ofrecord is an entity, identify the recipient ofthe record and the recipient's
title or office entity]
on W77111
-:
if,
Mailing a copy ofthe 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 to the following address:
Date,
[address; written notice mailed to the owner at the last known address of the owner as shown on
the current real estate tax assessment bool',s or current real estate tax awassment records satisfies
this requirement].
Si patu fApplicant
l aiq M . `bra
Prinz Appli N me
.� 16;,