HomeMy WebLinkAboutCLE201600147 Application 2016-10-24MS
Application for ZoninT Clearance
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # /O Date:
Receipt # Staff:
PARCEL INFORMATION _
Tax Map and Parcel: _..� ' � Existing Zoning MKI N �
Parcel Owner:��d
+
Parcel Address: l A6 l—Vt w m City C(kA1-LJ1N_—& (i LLt State ki A Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/wrAe concerning this project? � ( J\1 Im
Address : 04N)�( 1 _ City C(` XTILL `W f ldk State A Zip 72`t 6 �
Office Phone: (_) Cell # �. W 3._ Fax # E-mail t> 1 4: V } L-L C
I
APPLICANT INFORMATION
Check any that apply: Change of ownership ;�;7`Change of use Change of name New business
Business Name/Type:
Previous Business on this site ' -W1LR tX_V_-5
I
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information tha you can provide: P-Z'�(i ,1 1 20 CAA —aYGE= , I Li Si+ i3
W_�- t_ _SI �N41S OAP- wc— wI C- WF1F 'AIc, c �1 t� i
*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 my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
APPR AL :INFORMATION
] proved as proposed [ ) Approved with conditions [ ] Denied
] Backflow 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 i
site plan.
I ] This site complies with the site plan as of this date.
Notes:
Building Official _ `_ � Date C_
Zoning Official Date
--
Other Official _ _ Date
County of Albemarle Department of Community Development
401 Mclntire Road Charlottesville, `5,1A, 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/02/2015 Page 2 of 3
Intae to complete Me following:
S §)nLI,Is HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y IJ N
111 there be food preparation?
If so, give applicant a Health Department form. b_ RYVT'Pp"J,-L
Zoning review can not tefin un 1 we receive approval from Health
Dept. I'*X DATE
Circle the one that applies
Is parcel on private well o - ublic water?
If private well, provide 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 septic filic sewer?
Y N
Will you be puttin u an sign of any kind? If so, obtain prQ,)er
Sign permit.
Permit #
N
Will there be any new construction or renovations?
If so, obta' the proper Permit.
Permit # 4:�)l 1_0 - 11.31
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:y v
ll�mitted as:
Under Section: 01)
Supplementary regulations section:
Violations:
Y/N
If so, List:
offers:
P/N
If so, List:
G�����
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
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]
[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
F—MHand 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
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