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HomeMy WebLinkAboutCLE201700101 Application 2017-05-01Application for Zoning Clearance �9 CLE # a C l 3 Or 101 a ~ >ticav�Pf PLEASE REVIEW ALL 3 SHEETS OFFICE USE ONLY Check # If 0 / Date: Receipt # J' _ Staff: _ ©� Y PARCEL INFORMATION/ %� �/ � Q Tax Map and Parcel:C Jy I Existing Zonin r lu'` Parcel Owner: 14��N l c "1 1 U� 1 Parcel Address: r6 �' A 5�fttw OCL City State ZiKR20 (include suite or floor) PRIMARY CONTACT ` } Who should we caWwrite concerning this ro'ect' p J Address VI : City4EState V 1 6 Zi Office Phone► jj'tL Cell A%7�— E-mail C APPLICANT INFORMATION Check any that apply: of ownership Change of use —Change of name New New business / �Change Business Name/Type: � Ul & � INN 1 � 1� ��� l� Previous Business on this site Describe the proposed business including use, number of employee , 1 umber of shifts, available pa king spaces, number of vehicles, and any additional " f tion t t yo can provide: ���_ *This Clearance will only be valid on flic 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 tru and prate toAebest of my wle ge. I ave read the conditions of approval, and I understand them, and that I will abi e by them. Signature P ' ted c � f 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, x 117. [ ] 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 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 11/02/2015 Page 2 of 3 Intake to complete the following: Y "� Is use m LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y Wi 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 o es Is parcel o ! v r public water? If private well, provide Health Department form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the o is plies Is parcel o septic r public sewer? Y /O 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: V1 N l Permitted as: Under Section: Supplementary regulations section: Parking formula: Required spaces: Y /6) Items to be verified in the field: Inspector : Date: Notes: Vio tions: Y If so, List: Pro Y / If so, ist: Varia e: Y / If so, ist: SP's: Y / If so, List: Clearances: SDP's Revi sed 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,Key) Lek:�Ugr 0t[11� kg6 f— a, [County application name and number] was provided "/1-U Pj the owner of record of Tax Map [name(s) of the record owners of the parcel] and Parcel Number ?10 — I 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 4111 1 1 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 r1 Print Applicant Name 41 1l Date