HomeMy WebLinkAboutCLE201600237 Application 2016-10-17Application for Zoning Clearance
CLE#_ZJ(0._0 0
OFFICE U Y
PLEASE REVIEW ALL 3 SHEETS Check# Date: -
Receipt #::E Staff:
PARCEL INFORMATION
Tax Map and Parcel: 0 — 03 — — Existing Zonin IU f hL6. ►%cl% of r
Parcel Owner:���L
Parcel Address: —zo-]�5 City C.k l u t~ State Zip Zagi
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address- 2-2, Zr+,& &-- E lit 1 1�,_ City e]v!,L State Zip 2� `
Qfflce Phone: L _ l Cetl # kyj `J
t • c a cx3
J APPLICANT INFORMATION -
y p rope of o%vaership Change of use Change of narme X- New business
Check nn that apply; Clt „_---
Business NamePlrype: ik .a a'L—k lip
Previous Business on this site d�
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: et .5" �� -1-ew�fla► s �., ice( 2
�-i NL i I I t sr r L% s_ ,.
*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
Cicaranoe 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 Mty owledge. I have read the conditions of approval, and I unde�rsttand them, and that I will abide by them.
Signature Printed_ V � _ „----
APFROVAL INFORMATION
[' Approved as proposed [ ] Approved with conditions [ ] ponied
] Baokfiow prevention device and/or current test data needed for this site, Contact ACSA, 977-4511, xl 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. q t / _ �� 1
Notes. ii P nA(Yl t/1 ! , i< 1 r t ^}'1A r/n
Building Official .Date
Zoning Official Date
Other Official
Date
County of Albemarle Department of Community Development
401 McIntire Rand Charlottesville, VA 22902 Voice: (434) 2%-5832 Fax: (434) 9724126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y
Is u in LI, ,fil or PDIP zoning?
Engineer's Report (CER) packet
If so, give applicant a Certified
YJl N
ill there be food preparation?
If so, give applicant a Health Department farm.
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 ublic �+ ?
if privk-c well, provide Healt partment form.
Zoning review can not begin until we receive approval from Health
Dept, FAX DATE
Circle the one that ap es
Is pnreel on septic or ublic sewer?
Y i N
Will you be putting up a new sign of any kind? if so, obtain proper
Sign permit.
Permit #
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
YJ/ N -
ermitted as:
Under Section:
Supplementary regulations section:
Parking formula: If-5
Required spaces:
YJN
ItenfW be verified in the field:
Inspector • Date -
Notes:
Viol ons;
Y J(N)
If so, is
fifers:
Y N
so, List:
Va
Y N
ifs Est: �
S1P's�
Y J�
If so, ist:
Clearances:
SDP's
Revised I I 20IS Page 3 bf 3
CERTIFICATION THAT NOTICE OF TIM
APPLICATION HAS BEEN PROVIDED TO THE L ANDOW.I"+TER
This form must accompany zoning Wficadlons (Home Occupation, Zoning Clearance, Zoning
Admintstrator 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 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
Hand delivering 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
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 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 books or current real estate tax assessment records satisfies
this requirement].
xxw
Sign . re of Applicant jj [
-� U l�1
Print Applicant Tl a
91-u!l6
t`ate