HomeMy WebLinkAboutCLE201700059 Application 2017-03-06Application for Zoning Clearance
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CLE # C?l ���07T
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY l
Check # Date:
Receipt # �:' ��•5 � �%- Staff: rc„ri/
PARCEL INFORMATION
_
Tax Map and Parcel Ud -" �U^ - ii ( r! 5j Existing Zoning
Parcel Owner: �1��_r► , f l L i'} (/ 1- h c �• %S 4t �(�! �/
Parcel Address: I9X City d4y -A- z-;L/1'IState V� Zip
(include suite or floor)
PRIMARY CONTACT —� �
�M�/�
Who should we call/write concerning this project?- (WA. W
Address : I 1 �yo t �'" k& * A 1/ CitAi 4 It /Statey A— Zip %
Office Phone: ' 21 / Cell #-'AO(M _7U3-9ax # t3 � 2," 3 Z1 E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: h UkS, lleAll
Previous Business on this site Ui-Aid UA'VC- `-"
Describe the proposed business including use, number of employees, pumber of shifts, available parking s aces, 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 ify 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 d a rate to the best of y knowledge. I have read the conditions of approval, and I understand them, and that willabide by them.
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Signa
re Printed
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 i Date �—
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 I I/1/2015 Page 2 of 3
Intake to complete the following:
Y /
Is u�' LI, HI or PDIP PP
give g, so zoning? If iapplicant a Certified
Engineer's Report (CER) packet.
Y
Wil re 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 ub=wate'r9:)
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 app
Is parcel on septic o public sewer >
N
ill you be p ttmg Opa�n�e'w sign of any kind? If so, obtain proper
Sign permit.
Permit\#
Y /V J
Will ,yore 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:
®/N
Permitted as: OM Q 9--
Under Section: ZY.2
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N ✓
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/�
If so —, List:
Prof s:
y
If so, List:
Var' nce:
Y / 0
If so, List:
SP's:
Y /�
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, _A` Vag ;a k-,
C, W , [County application name and number]
was provided to V �� ✓� a owner of record of Tax Map
[names of the record owners of the parcel
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
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 qivqwwk � d, `— S' C.ii �(1
[Nam f the record owner if the recorA owner 's 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 3, � . I'� to the following address:
Date
IDS'21
[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].
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Signature of Aprplicant
C 6V IA'1 ho, WDfff
Print Applicant Name
(I")b,I-I
Date