HomeMy WebLinkAboutCLE201800195 Approval - County 2018-09-13APPRnvpf
Application r o. 1 , Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY It /t
Receipt # Staff:
PARCEL INFORMATION
Tax Map Parcel: 0�� 00 "
and
"1R)axisting Zoning
Parcel Owner:Llj
Parcel Address:Q'� �P Q� { j City e, State NJ Zip M
(include suitJor floorij
PRIMARY CONTACT
Who should^^w��.e call/write concerning this project? )L�t(- QUI/l8k )(- 6r14 , (
�_826 ' tnrk ; TT k 1iJty ' ptate
Address : i � Cit �"rr1�C� S M 5 Zip
Office Phone: ( ) Cell # 804-0a2-6122Fax # E-mail 1 f3242 czb
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APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: � ',� Z Is-s( �t tom
Previous Business on this site 2 M
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: nOr� y_e +C, 4 ( Z�j — �,t� eXN42(� fe
hr. • � s r � � ���cn �, C,� c� - � l �r ��v �..��_s�-, l �-�� � iL.n c: �-
*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.
1 hereby certify that I 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 the best of my knowledge. I have ad the conditions of approval, and I understand them, and that I will abide by them.
SignatureAtk4tt,,UBle_-A(lPrinted �� I �6e_yyS�
AP OVAL INFORMATION
[ Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-451 1, 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 Date U
Zoning Official Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page of3
Intake to complete the following:
Y / N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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 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.
Permit #
Wil ere be any new construction or renovations?
If so, obtain the proper Permit. 696,-
Permit #
'j
Zoning to complete the following:
L-0; C,3y3
Otum
Reviewer to complete the following:
Square footage'" I MA
ram, 1
l
Y / N
Prfmitted as:
Under Section: %1p
Supplementary regulations section: �) • ) - 11 C(
Parking formula: � _
Required spaces:
Y/N
IteAweo be verified in the field:
Inspector : Date:
Notes:
Violations:
Y / N
If so, List:
r fers:
Y �
N
so, List:
i
it �c
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
�� s
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Clearances:
SDP's
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Revised 1 1/I/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:
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].
g ture of Applicant
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Print Applicant Name
�i� ze�r 25
Date