HomeMy WebLinkAboutCLE201800182 Application 2018-09-05or
Application for_Clearance
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{Zoning
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PLEASE REVI3 SHEETS
EW ALL
OFFICE USE ONLY �
Check # C'5[A Date: t
Receipt # Staff: _
PARCEL INFORMATION
Tax Map and Parcel: Existing Zoning GJr
Parcel Owner:
Parcel Address: S �� City C wr y kate \/ft Zip��
(include suite or floor)50�
PRIMARY CONTACT Who should we call/write concerning this project?TVeA1-\d 6L
Address: (,j l
`� 1 �-6y-PJA ��� City 1' �� Statey& Zip
Office Phone: ( ) Cell # LOAC 3% Fax #
cd
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
d
Cz, Cl' V-V
Previous Business on this site �YAb�Ct%b .. �Q/�y C/Vy I C42A
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, numbe of
vehicles, and any additional information thatyou can provide: Fitts C�p�'�n y� �bGc iSiNc � E�i�Ct
tiW►
,�
*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 1 own or have the owner's permission to use the space indicated on this application. 1 also certify that the information provided
is true and accurate to e best of my knowledge. I have read the conditions of approval. and I understand them, and that I will abide by them.
Signature Printed �Q��� �(?J 2 .4 Yl a�S
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, x117.
[ ] 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 � %�I
Other Official Date
%Dunty oI AiDemarte uepartment of community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised I I/1/2015 Page 2 of 3
Intake to complete the following:
Y4N
Is u in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
Y /6
If so, give applicant a Certified
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
Circle the one that applies
Is parcel on private well or li�jlifit%t
r
If private well, provide Healt 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 Tic sewer?
N
-Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit Y 061\W AV -15 iIt
Permit #
Y
Wi t re be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: I � '71K
Y/N
rmitted as:
Under Section: , , � (4)
Supplementary regulations section:
Parking formula: C
toy
Required spaces:
Y/N
Items to be verified in the field
Inspector:
Notes:
Date:
Violations:
Y/N
If so, List: \
ZV'I 0 ao la -(3c�a ( s i�rui
Proffe s:
Y//
If so, ist:
Y/
VariTt"
If so,
SP's-
Y/Q
If so, List:
Clearances:
CLE
SDP's
,V) M iac a
0-777
Revised I I/l/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, jo�� j C-AcGl cance-
[Co my application name and number]
`J was provided to Tod d el&�U (n the owner of record of Tax Map
[name(s) o/f�the
' record owners of the parcel]
and Parcel Number Cj� l7�`^►C%�2/v'lS �V� by delivering a copy of the application in the
manner identified below: 5v►1-P,, Lb 0
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'roJA
[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] j
on _ () �! t�� J '� 1, K to the following address:
Date
-�-c64� C)&��Soyq
[address; written notice mailed to the owner at the 1 st known addr s of the owner as shown on
the current real estate tax assess►nent books or current real estate tax assessment records satisfies
this requirement].
M r-d b Cary z
Signature of Applicant
?/o-,pd6
Print Applicant Name
E-- X —
Date
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