HomeMy WebLinkAboutCLE201700088 Application 2017-04-12Application ing Clearance
OFFICE USE ONLY
I 'LEASE REVIEWALL 3 SHEETS Check # Bate:
Receipt
PARCEL INFORM �i��
Tax Map and Parcel: �l_Y�s.! _ y xisting Zonina liornmCO 14�Y
jParcel Owner:_1=—w
_ __„ � I�—arbf SA� orLI) DD,/ /�y� Parcel Address;� ' 5l� T��Mor� � � State �L Zip 2Zgb�
(include suite �r tlstor) Lf � j
1 PRIMARY CONTAi T
6vho should v�°e ca
lllwrite concerning this project"
i �o I' ��-.-- I -
Address : 6 0 ��L. fmoct 6TL qo( fit ! I� State _ VA Zip �'161
i ; _ 1
Office Phone: �i "_vttV� —cal J �"I— _ Fax
APPLICANT INFORMATION
Check any that apply: Change of ownership Cbaatge of rase Chaaage of name New business
—
Business Nane/Iy1 SeT, K4 /
b . LL C ,
Previous Business on this site
s
Lescnde u,e proposed business ancaudtng use, number of empioveees number of shifts, availa
%xehiclq , and any additional i�1formation that you can gravid : I I1��
*This Clearance will only be valid on the parcel for which it is approved. Ifyou change, intensify or move the use to a new location, a :yew 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 accur�e to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Printed K6 Uo-H, Flood, 6pt vaIl'n
.APPROVAL INFORIWATION
>4 Approved 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
Zoning Official
Other Official
Date cJY/
Date 9/Z��o
Date
Count} of Albe3n2rle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
c-./
Mz
Revised 11 /1/2015 Page 2 of 3
Intake to complete the following:
Y /a
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y I
Will be food preparation?
If so, give applicant a Health Department for:..
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on private well w6ublic wa�te')
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 applie,
Is parcel on septic pul�Iie seer?
-Vi -,NT
fViil you be putting up a new sign of any kind?
Sign permit,
Permit #
Reviewer to complete the folto-tving:
Square footage of Use: _3-1 0,5
-Y / N
Permitted as:
Under Section: -L J
Supplementary regulations section.
Parking formula:
IV 1—If
Required spaces: 1-5
Y ', 0
Items to be verified in the field:
If so, obtain proper 1 —
YCO
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Inspector:
Notes:
Date:
Violations:
Y /-P
If so, List:
Proffers:
Y!
if soost: 1
Varia e-
Y/V
If so, List:
SPIX
Y /
If sol�ist:
Clearances-
SDP's
Revised I1/l/2015 Page 3 bf 3
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, AN:) & 7-ow. rA C1 e a-rancc-
I 1 [County application name and mber)
was provided to � u �ia- rathe owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0 (o I VV 'f D 100 by delivering a copy of the application in the
manner identified below:
Hand delivering 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
ui����
a copy of the application to C cpai RQy , :SUC 0-ray
[Name offfie 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 to the following address:
IhS("6►"(a—V0, •C0rV1
[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].
Si azure pplicant
Print Applicant Name �--
Date