HomeMy WebLinkAboutCLE201600285 Application 2017-01-20Application for Zoning Clearance
CLE #6?DIto -ass
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # of 7 Date: 2 l
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: : �A, ( AI -r50 --(XJ-rDOZ.(0 Existin Zonin
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Parcel Owner• .z (�•-}� 1cR� » �' L:n
Parcel Address: City C ate —�nGl ; Zipz
i t
(include suite or floor)
PRIMARY CONTACT
Who shouldwe call/write concerning this prC
` 4ojecct?
Address: 090 i-UA. ,�QQ��C r 3DOCity Y , 1 State V a Zip�1
Office Phone: ( 7] - Cell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: 4-F kAf - s
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 appro ed. If you change, intensify or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify t at I own or h ve the owner's permission to use the space indicated on this application. I also certify that the information provided
is true
and accure to the best f y knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signaturej-
`I ✓ PrintedJAo)t �k�A 74 r
APPROVAL 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
a
Zoning Official Date
Other Official Date
L.ounty of Ainemarle 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/N
Is use in LI HI or PDIP zonin 9 If so i I'st C f'f d
Reviewer to complete the following:
Square footage of Use: LO .
, g. , g ve app can a er > >e
Engineer's Report (CER) packet. Ve
N
mitted as:-�,-tii'
Y / (� /
Will t ere be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well or public water?
If private well, provide Health ep7 a— m nt form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that ap
Is parcel on septic o public sewer?
Y '. N
i ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
/ N .
re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoninc to complete the following:
Parking formula:
-��
Required spaces: /
Y/ �6
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y / V
If so, st:
Proffe
Y /
If so, List:
0V riance:
i'/N
If so, List:
SP's:
0/N
If so, List:
Clearances:
SDP's
Revised II/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, U,6 0-90)to - ass
[County application name and number]
was provided to (2A E 0jfr-j,1An/) �nVO the owner of record of Tax Map
[name(s) of the reco o ners of Ke parcel]
and Parcel Number (Q I Y I" X by delivering a copy of the application in the
manner identified below:
4Z 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
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]. _.
Annlicant Name
Date
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