HomeMy WebLinkAboutCLE201600215 Application 2016-10-13Application f r Zoning Clearance A
CLE # ..
OFFICE E NIaY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFOR i
Tax Map and Parcel• NExisting Zonin
c
Parcel Owner: %!,.
Parcel Address: 'FLAB S , `nI 1 e r ,'I City C 6,1- 44e_%1k State vi r "m zip 124 0f
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project. CArAv&r
d j a c�n _
Address: [0 e r City G en-1-44 sv-11.e State _V i ! ciA l � Zip2 2 j J 1
U.. _.
Office Phone: (_� Cell # 4 34' 2364960 Fax # E-mail BI r-ck b e-f-P Sv ec a rr Ae"vw".
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name V New business
Business Name/Type: k44--, ) tVs4 'nJ
Previous Business on this site
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: 1 e "a4 ¢ Sclrt an f + bat sA1 I 1 a zd a e
*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
CIearance 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 knowledge. I have read the conditions of approval, and I understand
y them, and that I will abide by them.
t1
Signature _� Printedc i S �f'! I � C E R l�1` iTA Al
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
] Backilow 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 ~r Date i
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) 972-4126
Revised 11/1/2015 Page 2 of
Intake to complete the following:
Y/t
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Willt 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 or Jc ter?
If private well, provide ealth De ent form.
Zoning review can not bdg4wmff we receive approval from Health
Dept. FAX DATE
Circle the one that ap
Is parcel on septic r ve
YIN
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Vio ions:
If sb4ist:
Variance:
YIN
If so, List:
Clearances:
Reviewer to complete the following:
Square footage of Use:
J IN
l ermitted as: sv
Under Section.
Supplementary regulations section:
Parking formula:l
I l�
Required spaces:
Y/lu
Items to be verified in the field:
Inspector • Date:
Notes:
Revised 11/1/2015 Page 3 bf 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 orAppeals, 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:
V Hand delivering a copy of the application to
the owner of record of Tax Map
by 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].
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Signature o Applicant
CEl R S70 PHE ok,62- -Al
Print Applicant Name
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Date
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