HomeMy WebLinkAboutCLE201600288 Application 2017-01-06Application for Zoning Clearance,"�
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check# (85to Date: Z
Receipt # p`I to 5 1 Staff
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PARCEL INFORMATION `
Tax Map and Parcel: «,Q p { Aa-� LLCv- Cj(Q — 73Q 4 Existing Zoning
Parcel Owner:
Parcel Address: (� 4 City �� [yt� State
(include sui& or floor) Y�
PRIMARY CONTACT
Who should we call/write concerning this project? Poalvl
Address : —'� City kQ^A-( State('( Zip s
Office Phone: (_� Cell #,SL_ # E-mail fir/�?GtCer� u�
APPLICANT INFORMATION
Check any that apply: Change of ownership Change ofuse Changes of name New business
Business Name/Type: fI
Previous Business on this site '� m f <4
Describe the proposed business including use, number of employees, number of shifts, vailable parking sp ces, number of
ve icles, and a y dditional informati n that,ypu can provide: �. v
*T i Cleara ce will only valid on thefparcel for w h it is 4proved. 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 f my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
AP ROVALOINFMMATION
[ ] Approved as proposed [x] 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 co pliance w'th the existing
site
plan. / o Utxh; sc -5-41r)9 c, vV cQ15���`Ir v 1 fc Nis
[ ] This site complies with the site plan as of this date.
Notes: �' �TTT� (.l�1� ✓�eicjRll� �Q
t
Building Official - Date
Zoning Official 4 A 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 3
Intake to complete the following:
Y /
Is us LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
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 r public ater?
If private well, provide H&h epartment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies -
Is parcel on septic or qucse we .
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
ZoninLy to comDlete the followin
Reviewer to complete the following:
Square footage of Use: l�
/N
Permitted as: i 4,q)
Under Section: 2 9. 2-
Supplementary regulations section:
Parking formula: /
D
Required spaces:
Y/N
Items to be verified in the field:
Violat' ns:
Y/
If so, ist:
Proffers:
Y/(N�
If so, ist:
V Hance:
/N
If so, List:
SP's:
Y/
If so, List:
_<0
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 tl:e
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:
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].
Signature of Applicant
Print Applicant Name
Date
