HomeMy WebLinkAboutCLE201700084 Application 2017-07-27Application for Zoning Clearance"fey
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CLE #
PLEASE REVIEW ALL 3 SHEETS
OFFICE U E, NLY
Check # Date: -�
Receipt # Staff:
PARCEL INFORMATION
�/�,
Tax Map and Parcel: W - M _O( ` i(p Existing Zoning_ pDsa
U4
Parcel Owner: (Ani,� SRt 5
Parcel Address: L)ACity � State Zip
(include suite or floor)
PRIMARY CONTACT JWho
should we call/write concerning this project?
Address: S W - ere "It el4e-C City 6a 1rL"o-%. State Zip 36 -43
Office Phone: ?0 -W, Cell #'W4- W " Fax # &U— E-mail SiC-0IG Co A,
&`JJ -1360
APPLICANT INFORMATION
Check any that apply: Change of ownership of use Change of name New business
/Change
)�
Business Name/Type: Kr%—,n�J KTe.j4.,e, bc,uA I�iJS
Previous Business on this site
Describe the proposed business including use, number of employees, n�f shifts, available pnaf ki�tg spaces, number of
vehicles, and any ad itional information that you can provide: S� a- S t{�/ /Jo ik"tLi pc�.
*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.
1 hereby certify that 1 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 to the best of my_ knowledge. I have read the conditions of approval, and I undjerstand them, and that I will abide by them.
Signature ""-( ✓�`""� -Dort-,iZ{ 5 <-4,keiV
,G Printed
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-451 1, x1 IT
[ ] 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 '�� zwo
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 /0
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
J)/ N
Will there 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
Reviewer to complete the following:
Square footage of Use: 3050
6 / N
Permitted as: e,14, AWr•t
Under Section:
Supplementary regulations section:
Circle the one that applies Parking formula: s
Is parcel on private well �ater?
If private well, provide Health —Department form.
Zoning review can not begin until we receive approval from Health Required spaces: � /
Dept. FAX DATE /7
Circle the one thati�blic
Is parcel on septic sew r?
Y/N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
Y /
Items to be verified in the field:
If so, obtain proper
Inspector : Date:
/ N Notes:
ill there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # I b 11- 717 AJL
Zoning to complete the following:
Violations:
Y / &
If so, List:
Proffers:
6) / N
If so, List:
2.OA y
Varia e:
Y / 1
If so, List:
SP's:
Y / N�
If so, List:
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.
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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