HomeMy WebLinkAboutCLE201700047 Application 2017-02-17Application forZoning Clearance
CLE #
OFFICE E LY
PLEASE REVIEW ALL 3 SHEETS
Check # Date: - -
Receipt # Staff:
PARCEL INFORM��
Tax Map and Parcel: Existing Zoning _ 0A
f
Parcel Owner: t \ C 1 Cam r CAE
Parcel Address: City, ,,.4 { ; I l t` State
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: (a�22Ac+ City 't( State V Zip (V1
Office Phone: _?� Cell #%Drib 4tZS"`Fax # E-mail��y csc
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MN
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: a )Ct�>`�
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 informa ion th it you can provide:
�c - �t� vb,1��i
*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 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 accurate 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 c=>iLd�.-� Printed
V
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
Zoning Official DateLA z:z���
Other Official cj 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:
YNj
Is in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wil ere 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 o public wate •-
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
Is parcel on sep ' or public sewer?
Y
Wi ou be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper
Y IN
Wi ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: �)
�Z/N
Permitted as: /{t4
Under Section: -) -2— `
Supplementary regulations section:
Parking formula:
Required spaces:
Y /
Items to be verified in the field:
Inspector:
Notes:
Date:
Viol tions:
Y / N)
If so, List:
Proffers:
® / N
If so, List:
Variance:
V / N
If so, List:
SP's::111111GGGGGG
Y /
If so, ist:
;doo—
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, 01&,(& C I�e
[County application name and number]
was provided to c f i -F the owner of record of Tax Map
[name(spof the record owners of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
1 �✓
Hand delivering a copy of the application to
[Name a 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
rmt Applicant Name
X
Date
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