HomeMy WebLinkAboutCLE201600226 Application 2016-12-22Application for Zoning Clearance.,
CLE # p"04 rac;�p
�%Rfl, NAP
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date: 3 /&
Receipt # i�1 �Qy S5 Staff:
PARCEL INFORMATION
Tax Map and Parcel: %3 y A Existing Zoning
Parcel Owner:
Parcel Address: (� g l�ock%rt /at''City rZ�? State. Vol Zip ,�„Z�%
(include suite or floor) F—
PRIMARY CONTACT
Who should we call/write concerning this project? E
i r
Address: / 1 / Z- q `l � City C l :-t �i ate �� �
Zip
Office Phone: 3r C g Cell # b ` Fax #
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name t/^New business
Business Name/Type: �, �t,4' S A
Previous Business on this site fL % 'd
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number o
vehicles, anti any additional information that you can provi e: rt t •� i' H-'
2& st �e ss �-� - Q a r1 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
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 �_.�_. -PrintedL!61
APPROVAL INFORMATION
�Q Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x 117.
[ ] 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 1 o 1 4 t ( C.
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
lglf/'
Revised I I/1/2015 Page 2 of 3
Intake to complete the following:
Y /
Is use LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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
Circle the one that applies
Is parcel on private well qq public wat
If private well, provide He artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic o Pnewey?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followin
Viol ons:
Y /N/
If so, List:
Variance:
SUS/N
If so, List:
0
Clearances:
Reviewer to complete the following:
Square footage of Use:
9 /N
ermitted as:
Under Section: 29.2 .
Supplementary regulations section:
Parking formula:
%ao r
Required spaces:
Y /j9 i
Items to be verified in the field:
Inspector : Date:
Notes:
Proffers:
Y /
If so, Est:
SP's:
Y V
If so, List:
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.
1 certify that notice of the application,
V
[County application name and number]
was provided to AClty Gl At - the owner of record of Tax Map
[name(s) of the record owilers of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to 'k,f1 M . 7 6'jt
[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
C,C pry\ r2_ C-e4 10 f—
[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
�I /,�?rI ar7C4
Print Applicant Name
/YZ/ ) 4
Date