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HomeMy WebLinkAboutCLE201700044 Application 2017-02-22Application for Zoning Clearance CLE#oougq OFFICE USE ONLY PLEASE REVIEW ALL 3 SHEETS Check # C S Date: Receipt # "'J Staff: PARCEL INFORMATION Tax Map and Parcel: 00 oty- Q©,� ©b Existing Zoning Parcel Owner: r!� 0 / , (/7Y? a', Parcel Address: (c(3 Szml rno\ e -7rcct 1 City C PAo-k Syt fg State 04 zip ZZ-90� (include suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? RU P­QA0 Address: q 82 ECl P S e C�- City CkArlo {-•eSUt J k State VA Zip Z2.Q0/ Office Phone: �i( 34)� (� -ec36 Cell#'434 531 391•7Fax# E-mail J•e ►��-c }orePair_Luille �q APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name/Type: Previous Business on this site =� Zd� �'(� j✓'e �s �+ �, fS T 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: *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 Printed 12 J;/—,2 X1'Xn S a.ac 4aL APPROVAL INFORMATION ['Approved as proposed [ ] Approved with conditions [ ] Denied [ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-451 1, 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 7 Other Official Date County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 7.1 .1: CLI Revised 11/1/2015 Page 2 of 3 Intake to complete the following: Y /�Is use LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. 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 pu �partment ter? If private well, provide Hea 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 public 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, obtain the proper Permit. Permit # Zoning to complete the following: Reviewer to complete the following: Square footage of Use: (9 / N / Permitted as: ��}/) a'fi T) Under Section: Supplementary regulations section: Parking formula: Required spaces: Items to be verified in the field: Inspector : Date: Notes: Violations: Y /� If so, List: Prof s: Y /W If so, List: Variance: t/N If so, List: SP's: (V/N 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, [County application name and number] was provided to �� �� �� j , E �. L L the owner of record of Tax Map [name(s) of the record owners of the p el] and Parcel Number WO -- ©q -ZZ41- U®,-� y U by delivering a copy of the application in the manner identified below: Hand delivering a copy of the application to Y►'t t '�r o p'oI QS LL C. [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 ©Z- I S— 201 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]. _ J0410 SCr �i r) K,7 4S;i;na,4ueof Applicant Print Applicant Name dZ Date