HomeMy WebLinkAboutCLE201700286 Application 2018-01-19Application forZo n learance� R
CLE
OFFICE U Q Y
PLEASE REVIEW ALL 3 SHEETS Check # "l I Date: 1
Receipt # Staff: '�• "
PARCEL INFORMATION Q ctN v ?? Ve ( w
Tax Map and Parcel: 0 ;:_Q Q " (� 0 - (t - O L(1 b ( Existing Zonin��—`^
Parcel Owner:
Parcel Address:>�br V City. tr .4 AVState % Zip o d 1 1
(include suite or floor) �L
PRIMARY CONTACT ,
Who should we call/write concerning this project? c
Address : �y 1 U/� CityJ oay `w, State V [ 4 Zip`'��%3 �
Office Phone: - q q Cell # t, Fax # E-mail
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APPLICANT INFORMATION
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Check any that apply: Change of o(w�neershipp Change ofI use Change of name New business
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Business Name/Type: t�i A r1 l l l SS
Previous Business on this site I v ���yl' GAS �e�a� l r?1►ti"L7' �j �tt
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Describe the proposed business including use, number of emplo Bees, nu her of shi , available r g paces, number of
vehicles, and any informati 4
add'tional nth t you can rovide:
Or
a r
Or ' ' -, Irtii ttlr =
'II
his Clearance only be valid on the parcel for which it is ap ed. If yo0t1hang%e, intensi or move the use a ne 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
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is true and accurate to e best m eknowledge. I have read the conditions of approval, and I understand them sand that I will abide by them.
Signature Printed L�C it� y (nq (0S
APPROVAL INFORMATION
[Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] B ckflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ o 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 L`]
Other Official Date
.....� — —��R lC 1�Vtrdl unCui v< •.ommum[y mVetopment
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 2%-5832 Fax: (434) 972-4126
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
Y 1e,:J
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
Wi 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 public water?
If private well, provide 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 septic or public sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
it
Permit# Vic�ld te� v�lPpQ; ite1fY1
Y/N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # t,
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use:
i do �t _L
PerN
mittedas: ln4 c/ WWI(, Fquld-j
Under Section: Z S� . Z• 1
Supplementary regulations section:
Parking formula:
i f I Z5-
Required spaces:
1 / I VF _ 7
Y/N
Ite be verified in the field:
Inspector :
Notes:
Date:
Vio ons:
Y N I
Ifs st:
Proffers:
Y/N
If so, List:
�lA
Va ' ce:
If k IV
If so'list:
SPA
if
If st:
Clearances:
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SDP's -LOI
PAC,) Pd W I r1 �
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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:
Q 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
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