HomeMy WebLinkAboutCLE201600255 Application 2016-11-22Application for Zoning Clearance
CLE # o�/�p •�S�
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OFFICE U E QNLY a
PLEASE REVIEW ALL 3 SHEETS
Check # W Date: ( I
Receipt # Staff:
PARCEL INFOR I N
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Tax Map and Parcel: Existing Zoning_ ,
WParcel Owner:
Parcel Address: ��_�� City 01W],� tate Zip1L�—
(include suite or floor)
PRIMARY CONTACT �pp
D1EF
Who should we call/write concerning this project?
Address: 11f,5 W6TWjL G+ City (i(/ �� State VA Zip Z2 t
Office Phone: C00cell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Changeofownership Change of use Change of name New business
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Business Name/Type: %ll�t[ �' 9�
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:
*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-understandthem, and that I will abide by them.
Signature Printed
APPROvXL 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 of this date.
Notes:
Building Official Date
Zoning Official Date 12/1261,
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/l/2015 Page 2 of 3
Intake to complete the following:
Y/N
Is us i L1, HI or PDIP zoning? If so, give applicant a Certified
Engin er's Report (CER) packet.
Y nN
Wi l 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 DATE
Circle the one that applies
Is parcel on private well r ubl ater?
If private well, provide Hea epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap s
Is parcel on septic ublic sew r?
Y N
Wi u be putting up a new sign of any kind? If so, obtain proper
Sig ermit.
Permit #
Y /
Will e be any new construction or renovations?
If so,QOtain the proper Permit.
Permit #
Zoning to comnlete the following:
Reviewer to complete the following:
Square footage of Use: 2- () V
�V/ N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula: ' /, 7;
-0
Required spaces: 1j
Y/Lp
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/5
If so, List:
Proffers:
Y/6)
If so, List:
Varia e:s:
Y /
If so, ist:
0/'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,
[County application name and number]
was provided to au(en y R91W 11 the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
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]
m
Date
V Mailing a copy of the application to -M (-AI1�1, k(Q,
[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].
nature of Applicant
b cA�L10-
Print Applicant Name
Date