HomeMy WebLinkAboutCLE201700135 Application 2017-06-07Application for Zoning Clearance
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OFFICE US��O NLY � / /�
PLEASE REVIEW ALL 3 SHEETS Check # 6'— Date:
Receipt # c Staff: ��
PARCEL INFORMATION
Tax Map and Parcel: " / ;I— — "q I Existing Zoning
Parcel Ownen 43 T(iw PcA , ! _��
Parcel Address: ("o � l3erL/Jj�� City ) d 4k 5t to Zip `Z-
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address: /� �`�'�(t !/ )') 6 �> City -1 ` (` (� State (s��
Zip
cxj f °
Office Phone: 0' Fax # -�� E-mail rCsj /
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: r 1
Previous Business on this site
Describe the proposed business including use, number of employees number of shif s, available parking spaces, 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 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 accurate t e best of my knowledge. I have read the conditions of approval, understand them, and that I will a ide by them.
Signature -eC 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, 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 Date����
Zoning Officia Date
f
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 11/1/2015 Page 2 of 3
Intake to complete the following:
Y/N)
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Will ere 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 ter?
If private well, provide He artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appl
Is parcel on septic o publics r?
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:
Violations:
If /
If so, —List:
Variance:
Y /
If so, ist:
Clearances:
Reviewer to complete the following:
Square footage of Use: % _5 60
Permitted as:
Under Section:
Supplementary regulations section
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Prof s:
Y /
If so, List:
SP's:
Y /
If so, List:
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
the owner of record of Tax Map
and Parcel Number 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
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
Print Applicant Name
Date
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