HomeMy WebLinkAboutCLE201700272 Application 2017-12-08Application for Zoning Clearance�y
CLE #
A'ry
�IRCIN�P `
PLEASE REVIEW ALL 3 SHEETS
OFFICE E ONLY
Check # 355 Date: �. 7
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: V 7 k rn1 —o c -D Existing Zoning
Parcel Owner: _5 +"'}(35 Vaftd WA Sik_�m)
Parcel Address: JW 'ag"", Sf- City State 6 � Zip c9Zi-3
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Jpy, p 64-1c)a rn p-)
Address: l q31 U P) ng-r)4lc).1 I k,gct- P), City State _y t4- Zip
Office Phone: (e_ab 334 - 7--fi4Cell # s,omr Fax #90l-739919c( E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ---New business
Business Name/Type: 6-,? e,4-i_ ;1 -, _ .i, use- $ram bp-iz SAC, I
Previous Business on this site 1 ` +- OC C w rt2,1,t 7
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
vehicles, and any additional information that you can provide:r2
`Yl i r-+ . 3 5" bl-Ts, 1
*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 the best of m knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed
AP OVAL INFORMATION
[' Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Xckflow
prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
[ inspection
o physical site 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
n
Zoning Official Date_ 7 1 1-7
Other Official Date
�.vuuay ui-luvinarlc Lcparlment oI t-ommunity 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 uSQ LI, HI or PD1P zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y
Wil 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 or lie water?
If private well, provide Heal ep ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic orb, is sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit# 'dVPLt
Y/N
Will there be any new construction or renovations?
If so, obt ' t M.er t.Permit #,
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: 3 � 0 — FI Z/
Y/N
rmittedas: Ate Y- bPa S�G
Under Section: - ITA • 2 . [ C 1 j
Supplementary regulations section:
Parking formula:
Required spaces:
Y /( N\
Ite be verified in the field:
Inspector • Date:
Notes:
ons:
YWi/
Ifs}-} ist:
Hers:
Y N
o List:
ZCVq-' I
':
Y
VM/N
If:
SP, .
Y/N
If s , ist:
Clearances:
new (e
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,
[County application name and number]
was provided to 5 jA4-&y U*3-NuIzeD LL C- the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 0-)(Pln did z by delivering a copy of the application in the
manner identified below:
Hand delivering a copy of the application to -Dj-,./ Tuctc6-- -�Z-
[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 l7)jE-7c — 20j
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
I�l}y'i✓.� �una�-1
Print Applicant Name
/Z- T._
Date