HomeMy WebLinkAboutCLE201600214 Application 2016-10-10Application for Zoning Clearance
CLE # o -aiy 191
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # 15aS3 Date:
Receipt # Staff: Jf
PARCEL INFORMATION
Tax Map and Parcel:—0,G tjj f_5 — ®f — pG 0()j 0J Existing Zoning
Parcel Owner.-- CA 4
Parcel Address: ! �/11�t''t city1 yy rr//AA Za
/r�H/l State l� Zip2 /&2-
(include suite or floor)
PRIMARY CONTACT
Who should we call/write con erning this project?
Address : `( J a } Il_ City C V State vA Zip
Office Phone: 6% Cell # 5 �/T 33� 3�p ax # E-mail
i11 l�iln! S%i1 l'hd�� J , CdJ'h
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
Previous Business on this site ot, W_f
YL t
Describe the proposed business including use, number of employees, number of shifts, available par sing spaces, number of
vehicles, and any additional information that you can provide: oy-etj /� Ve Pa *y
*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 best of m o ]edge. I have read the conditions of approval, and I u erstand them, and thh l will abide by rm.
Signature Printed . ]/
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 ofthis date.
Notes:
Building Official �~ Date ct ,),-a
Zoning Official Date 1011A4&Ld
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 11/1/2015 Page 2 of3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
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
Reviewer to complete the following:
Square footage of Use: �jz 0::
0/ N
ermitted as: AALeV. r
Under Section:
Supplementary regulations section:
Circle the one that applies Parking formula:
Is parcel on private w or public water. ��/Seamy 5c v hR
If private well, provide Ith D ent form.
Zoning review can not begin until we receive approval from Health Required spaces: /
Dept. FAX DATE
YI
Circle the one that app ' Items to be verified in the field:
Is parcel on septic public se ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector : Date:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the followin
Violations: Proff s:
Y/ Y/Y
If so, ist: If so``, ��ist:
Variance: SP's:
YI( YI
If so, ist: If so, List:
Clearances: SDP's
Revised 11/1/2015 Page 3 bf3
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.
1 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:
Hand delivering a copy of the application to
the owner of record of Tax Map
delivering a copy of the application in the
[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].
Signature of Applicant
Print Applicant Name
Date