HomeMy WebLinkAboutCLE201700016 Application 2017-02-12Application for Zoning Clearance"
CLE # ZC> (� _ ���'
OFFICE acrSy
PLEASE REVIEW ALL 3 SU HEETS Check # Date: "A C'
� \S .
PARCEL INFORMATION .'j
Receipt # Staff:
Tax Map and Parcel: "j 45CL4 Existing Zonin
Parcel Owner: �1 i �.tV. ' �n
Parcel Address: i91 City tFjkcill State VA Zip`ZZ-'
(i clude suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? �✓►'l.�
Address :_.� �La kju City [cc)a State (� -A zip Z
Office Phone: ( 77 -) O --Cell # =131770 Fax # E-mail C ✓&A e �4"',"-"
APPLICANT INFORMATION
rcpny
at apply: Change of ownership Change of use Change of name New business
e/Type: Win,, 1JTs_ ��+� �T�te�► v u�
iness on this site_
c
roposed business including use, number of employees, number of shifts, available parking spaces, number of
any additional information that you can provide:t
*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 Abesedge.
's permission to use the space indicated on this application. I also certify that the information provided
is true and accuI have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed �/s V'-APP VA
( 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 q ��
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 I I/1/2015 Page 2 of
Intake to complete the following:
Y4;Ll,
Is HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wil re 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 or pu lic wat ?
If private well, provide Health ment 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 p b c sew .
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
Reviewer to complete the following:
Square footage of Use: 9-ys�
rmitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y �Ite s4a e verified in the field
Inspector:
Notes:
Violations:
Proffers:
Y/N
Y/N
If so, List:
If so, List:
Variance:
SP's:
Y/N
Y/N
If so, List:
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, C L 2-0 T — 1
[County application name and number]
was provided to a owner o PecUroXaxMap
[name(s) of the record owners of the parcel]
and Parcel Number _ i !s C, L� by delivering a copy of the application in the
manner identified below:
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].
Signature of Applicant
Print Applicant Name
Date
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