HomeMy WebLinkAboutCLE201600200 Application 2017-02-16EP
pplication for Zo in Clearances%�
CLE
OFFICE U LY
E REVIEW ALL 3 SHEETS Check # Date:
Receipt # `� Staff:
RMATION /
el: �CP _ p — 0?ODO Existing Zoning G�
1 Q dyaryj� City 0 -r� State VIOL Zip �✓
(include suite r floor)
PRIMARY CONTACT TT
Who should we call/write concerning this project?_1 r t J O` U.)0-
Address City r 0 Q�- State Q . Zip 73
Office Phone Aq_S r Cell # Fax # E-mail
J6U¢ �fr G r rA-CotM
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: 6 Cro Cre,o.. ny!Zam O
R (1!4-�
Previous Business on this site No 0 me
Describe the proposed business including use, number of employgxs, number of shifjts, available parking spaces, number of
vehicles an any additt al informatio that you can provide: GQ� G�'�M•vtcsyDiO ��•,!/!/2 Gg�,�p�
k_s - / z �,>�yZ'ts
*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 I or have the owner's permission to use the space indicated on thilication. I also certify that the information provided
is true and accurate the est of y knowledge. I have read the conditions of approval, an erstand em, and that I will abide by them.
Signatur Printed�O' 14
AP�P� pproveAL INFORMATION
[ d as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ ] 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 S-(( L
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 N
Is u LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
ill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we r ceive approval from Health
Dept. FAX DATE �{ ��.�, ,
Circle the one that applies
Is parcel on private well or p(blic Ovate .If private well, provide Health meet form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic or ublic sewer?
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, obta�Ay,;O!M
inn
Permit #
Liu 11111g lu l:ulllpjwzty 111C lulluW111g.
Vio ns:
Y/N
Ifs st:
V I Kan
Y V N
Ifs Szus t:
Clearances:
Reviewer to complete the following:
footage of Use: 6 (D5,
Y/ N
Permitted as: ' AR. ( l
Under Section: `�v /
Supplemeregulations section:
DEntary
Parking formula:
2
Required spaces: / , \
YIN)
Item o be verified in the field:
Inspector : Date:
Notes:
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].
Signature of Applicant
Print Applicant Name
Date