HomeMy WebLinkAboutCLE201700193 Application 2017-08-2908/12/2017 00:04 4342962503 CACF PAGE 01/04
Application for Zon in Clearance
CLE # v 00
I �
— - --- -- OFFiCE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Recelpt # Stf-
PARCEL INFORMATiON
Tax Map and Parcel: -710 00 _6 O �jt j_p 1C; Existing Zoning —
Parcel Owner.
S► a� ar s
r Yo Arp a �9Parcel Address: City ar 0 tale Zip o?o
(include suite or floor
PRIMA.RX CONTACT
Who should we call/write concerning thin project?
Address : 1 I g4. g- % - City state Zip
-------- - ---
���y�
Office Phone. 11 �/► �7 `�0 Cell # -9—_!
,APPLICANT INFORMATION
Check any that apply: Change of ownership _ Change of use _ Change of name New business
Business Name/'type:
Previous Business on thls site
. Deaerlhe the proposed bnsinet<s including use, number of employees, nutttwbe is av flab park sp tes, � IuerdlAq
Vehicles, and any additional information that you can provide: FA L f1 , J4 ` �. iJ
*This Clearance will only be valid on the Parcel for which it;? apprnved. If you change. intensify or trove the use to anew location a new i oninn
Clearance will be required,
I b.crcby certify that 1 o bavc the owner's pe ion to use the space indicated on thus application. 1 also certify that the information provided
is trite are, accurat N b t <'r my know dga t c read the conditions of approvn4. Arid T unders d them. at d 419`Will abide by them.
Sxgnatur,_ t ^�
APPROVAL INFORMATION — --
>'Apprc;vcsl ae proposed [ j Approved vritb conditions [ ] Denied
is l BtxekPo'w prevention device :indr:�r current test datt+ needed for tlue site. Contact ACSA, 977-451 1. x11.7.
, No , hys.ical site inspcctior, hats been done for this clearance. Therefore. it is not a determination of compliance with the existing
site pion.
[ 1'I tine mite complies witJ� the si°,-- plan as of t.bie d� tc
1'�'otes:
------- — - - ------ --- - — --- —
Wt ing 01ficlal —_ _ .�' Date � y
Zon ing Official - — --- _ Date-, - --
Other Official
Date
County of Albemarle Department of Community Acvelopment
401 )4cTntire Road Charlotickville, VA 22902• A'aict: (434) 296-S832 Fax: (434) 972-4126
Revised 1 1/02/12015 Page 2 of 3
08/12/2017 00:04 434296250a CACF PAGE 02/04
Intake to complete the following:
45 u" U. HI or PDIP honing? If -.n, give spplicanl a Certified
Fngincer's Report (CER) packet.
wil Ncrc be food preparation? (OrAow ' """' - /
If so, give applicant a. Health Department form.
Zoning review can not begin until we receive approval fYom Health
Dept, FAX DATE
Circle the one that applies
Is parcel on private we r puhlic w9tcr?
Tf private well, provide 1-tea ment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE _
Circic the one that applies
Is parcel on septi lie sewer
Y /
Willa be pictting up a new sigu of any kind? If so, obtain proper
Sign permit.
Permit #r
Y /
Will �tere be any new construction or rcnovation.0
If so, obtain the proper Permit,
Permit #
Zoning to c
Violations:
Y /:
If so.
Y /W
if 90, List.
Clearances:
the followi niz:
Reviewer to complete the following:
Squarc fool:nge of Usc:
O/N
Pennittcd as: M/1Ll�°f
Under Section: 7f
Supplementary regulations section:
Parking formula �_----
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Proffc a:
Y /
If so, List:
Date:
SP' Q:
If so, List:
I
Revised 11 /1 /2015 Page 3 03
08/12/2017 00:04 4342962503 CACF PAGE 03/04
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany Zoning applications (Horne occupation, Zoning Clearance, Zoning
Adoninistrator Determinations or appeals, Sign Permits, Building Permits) if the aWicrttion is not the
owner.
1 certify that notice of the application,
A;d a
( ounty application nawc and number]
was provided to S t at,
the owner of record of Tax Map
[name(s) of the record owners of the parcel]
J ` b delivering a co of the application in the
and Parcel Number ,., � r Y g copy pp
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
Moiling a copy of the application to
S , an k" GkAds
[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 th t ent tv]
�
On
7 to the following address:
Date
(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 rccords satisfies
this requirement].
—4 AA
SignatureAA Ap lint
Jrgj 1 A
Print Applicant. Name
Date
__
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