HomeMy WebLinkAboutCLE201700027 Application 2017-02-15Application f r Zonin ClearanceIP
OFFICE S N V
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PLEASE REVIEW ALL 3 SHEETS
Check # Date: C
Receipt # Staff: ✓,s'
PARCEL INFORMATION
Tax Map and Parcel: Za)c Ain - RrC ol ZI- C Existing Zoning (G tJl
Parcel Owner: Am ttSSoU S L(- C
Parcel Address: (06 ZLt P14 n k Q _ CitybM<State /-+ Zip—O't L4
(include suite or floor)
PRIMARY CONTACT �+
AIRY
Who should we call/write concerning this project? Ji -L)6J Jv1 !)
Address : 6((Z� pI Q h Ic I�GI � 23 � City 13A4 S�/1 l � p State \J Iq Zip.Z Z 1Z4
Office Phone:ell # Fax # E-mail hex S1(Urr+ /b�Q j� cnM
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: gaime2� LL. C tq
,,�� II ' a
Previous Business on this site &rVS\J,l'I-P � a k-4
Describe the proposed business including use, number of employees, number of shifts, a ailable parking spaces, number of
vehicles, and any additional information that ypNN SSan provide: / (a Sc C"',,A
3 4 0410 J2 n Y.CC., '4 6 C Q <
*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 Idt
h e the owner's ermission to use the space indicated on this application. I also certify that the information provided
is true and accurate tAe. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Al-�Qr�A d" �, /Y1 �✓laQ
APP"VAL INFOR ATI N
[ pprcved 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 ( l
Zoning Official e' 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/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
/N
ill there be food preparation? V pP-t_-s
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 a Thes
Is parcel on p ate well or public water?
If private we '�eHealth Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on epti or public sewer?
Reviewer to complete the following:
Square footage of Use: 5 �U
/N
d as:
Under Section:
Supplementary regulations section:
Parking formula: *M pf l� Q
1 c 31 tV'� J
Required spaces:
Y/
IternVti6 be verified in the field:
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit # Inspector
Y / N Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Gonme to complete the iollowin
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances: �U I � � � �
SDP's
Revised II/1/2015 Page of
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
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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