HomeMy WebLinkAboutCLE201800183 Application 2018-09-05Application for Zonin Clearance
CLE # 1 V 1
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: ( _ , ��``)C, -- 00 — C �Q(G Existing Zoning
Parcel Owner:—(�^C-1 rfm_k; , `cr
Parcel Address: q 1'jf /1 C'' 1' f TI—ell City F-� CW � C State V? Zip , o
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?�I
prrojjeect�? (� r?
1
Address : Qq 6, F Laurel re I l�.lf� I�L,7 City Y1 MV l State �IA Zip l
j�,d
Office Phone Cell # 5 )SEX �V� _E_mail e� �j pE'p (
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type:
[AnA nc- POYA ge ( ��^^ lam 1n �y P /
. am-3Iy.`�' f a �, ri r)K6 -t
Previous Business on this site r
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number f
vehicles, and any additional information that you can provide:
*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 to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed UV
APPROVAL INFORMATIO
[ ] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ ] 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 C/G `%�L
Date C
Zoning Official Date
Other Official Date
County or Atnemarie impartment of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
En
Revised 11 /02/2015 Page 2 of 3
Intake to complete the following:
Is / 1�I
Is UsPin LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
nN
Y 1Tih 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 a lies
Is parcel private well r public water?
If private w e Health Department form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel o septic r public sewer?
4N
l you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y
Wil ere 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: `q (,p y
N ermitted as:
Under Section:
I [q' stp
Supplementary regulations sect io
Parking formula:
Required spaces:
1�
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/N
If so, List: ��.^,�
Prof
y /
f so, ist:
Vari e:
y
Ifs ist:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
I
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, A I UuTr l-e Cowhi
[County application name d number]
was provided to GQN (+° ( (6hl [ e, L`�1 the owner of record of Tax Map
[na—� f the recor owners of the pdrcell
and Parcel Number
manner identified below:
by delivering a copy of the application in the
LVOQbqjHand delivering a copy of the application to J
[Name f the record owner if the recordowner 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
D to
® 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 Applicant
IIv ?q-7E
Print App4ant Name
81-T
Date