HomeMy WebLinkAboutCLE201700111 Application 2017-06-05Application for Zoning Clearance
CLE # XQ(� -OC I I I
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OFFICE U E ONLY
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PLEASE REVIEW ALL 3 SHEETS
Check # (�3 O Date: /b l --
Receipt #
PARCEL INFORMATION -7
Tax Map Parcel: I W M C
and Existing Zoning
Parcel Owner: v\UII�� �-% (� �Sl 1 U lJ� 11�J A—�
Vip
Parcel Address: 4 V\) `��)�(Z�� C. r� City CV 1 LA- C State Zip -2 LY"
(include suite or floor)
PRIMARY CONTACT per,
Who Lku CL�
should we call/write concerning this proiect?
Address: 4.} Q I N1 U k-c C 1 0 6 / City CV I UC State UA-Zip Z 0� t!
-
Office Phone: I �{ �L Cell # (` I SL Fax # L'N-67-3J E-mail L'�� S,�C=
APPLICANT INFORMATION
Check any that apply:'' Change of ownership Change of use Change of name New business
Business Name/Type: 1L -- IZ_,�
Previous Business on this site �\A a 6U � � � (,-- (J � _Zf
Describe the proposed business including use, number of employees, number of shifts, available parking sp ces, umber of
vehicles, and any additional information th t you can pr vide: 0 k k ►r
*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 accurat to the best of my knowle ge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed L r D • ' " l ' 1 - J /�
AP OVAL 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 Date
Zoning Officials.J Date
�r
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:
Is /
Is us mLl, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y
Wi zre 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 or ublic water?
If private well, provide Healt Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel o septic r public sewer?
Y /
Will be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y / QWill 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: 6, C L D
J/ N
Permitted as: unpC'
Under Section: I
Supplementary regulations section:
Parking formula: 1 � �
Required spaces:
Y N
Ite be verified in the field:
Violations:
Y/N
If so, List:
offers:
Yf/N
Ofso, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 11/l/2015 Page 3 of
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, vo C Q,
[County plication name and number]
was provided to le4� i,4 LA v A �& V the owner of record of Tax Map
[name(s) of the Pecord owners of the parcel]
and Parcel Number -JR- 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
ES6Mailing a copy of the application to —�k U V t�- F U1YJ"l Yl
[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 q 1 -2, 11 1 to the following address:
Date L
[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].
LA^�Vqa:, - —
Si ure of Applicant
LAM VL (�- N NA t11 P /►)
Print
/Applicant Name
Date
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