HomeMy WebLinkAboutCLE201700077 Application 2017-03-24Application for Zoning Clearance
CLE # —2,W 7 r 7 %
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # Date:
Receipt # AL2 R Staff:
PARCEL INFORMATION
,
Tax Map and Parcel: � J
�5 Existing Zoning
/�`
Parcel Owner: r',m% r\ S J 1C
Parcel Address: ��� �, �;� , ,�A,fe_s City(—, (c �d�Z State q zip.)a
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning S 4e- d'e_ K rt\ V-N n
-this \project?
Address: b�(� �.� `►C,_ 1\c; City State Zip c:IC O
Office Phone: 76 1 Cell # 434 ax # E-mail S ArQai1 n Q
APPLICANT INFORMATION
Check any that apply: of ownership Change of use Change of name New business
'Change
Business Name/Type:
Previous Business on this site
Describe the proposed business including use, number of employees, number of hifts, avai ble parking spaces, number�f
ve icles, and any additral information that
you vn provide:` �� V e �c 1 C'r?, i L G a
�
*This Clearane will Aly be valid dn the parcel for which it is approved. If you change, intensify or4nove theAe to a new location, a n w 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
to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
is true and aS41,ci
Signature ( Printed C
APPROV FORMATION
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 Date SLz-y o)i
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Cu �
Revised 11/1/2015 Page 2 of 3
Intake to complete the following:
Is/
Is usV4 LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y 1
Will t e 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 wat ?
If private well, provide Hea ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applie
Is parcel on septic or ublic sew ?
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: 1SU0
6 / N
Permitted as: IDT c£S, Q'kj G,Q
Under Section: �Z-3 , 2.
Supplementary regulations section:
Parking formula:
Required spaces:
Y/
Item o be verified in the field:
Inspector : Date:
Notes:
Violations:
Y/N
If so"LiA:
Proffers:
Y/
If so, ist:
Vari nee:
Y /
If so, ist:
SP's: .
If /
If so, ist:
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.
1 certify that notice of the application,
[County application name and number]
was provided to T \�S �� C u c 1._S the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to � c J 1�,r c)� n
[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].
Siigg o pplicant
Print A plicant Name
Date