HomeMy WebLinkAboutCLE201700034 Application 2017-02-15Application for Zoning Clearance"
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OFFICE MILY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff:
PARCEL INFOR
Tax Map and Parcel:M- Existing Zoning
Parcel Owner:
Parcel Address: 19 1 City State Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? 89T.�-(G iA /R
Address: o/0 City sTr�i%�✓— � �� 6 /
c� Y TOO) State !�}} Zip
Office Phone: S S r Cell # J./}y-yX t% Fax # E-mail f'/}1-T y /Zi S 5 �i Cryyt g L
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ew business
Business Name/Type: /}-n _ C �t 7- /7 /� L1__ C_
Previous Business on this site 7� L/ (�
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: .� i✓; / lip / 1/�N;,r� ���� ,
*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 certi hat 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 accurat 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 w /� Printed IDAT- - ct q IZ
APP AL INFORMATION
[ pproved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x1]7.
[ ] 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
tl
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
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Y
Is ust4 LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will e 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 ublic water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic kpublic sewer?
/N
Y
ill you be putting up a new sign of any kind? If so, obtain proper
Sign per'
Permit # S-b.
Y /q Will t ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
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Violations:
If / ,
If so,"Id st:
Variance:
Y/N
If so, List:
Clearances: `
Reviewer to complete the following:
Square footage of Use: 10100
V/N
ermitted as: Inbky S aL,
Under Section: jo 6, a
Supplementary regulations section:
Parking formula:
pn') I 16 b b V1 �-Ck-
Required spaces:
Proffers:
If /�If so t:
SP's:
If /
Ifs, Est:
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,
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].
ignature of Applicant
PAT2rC I f-� - Roo c-T5
Print Applicant Name
-7- 1-7
Date