Loading...
HomeMy WebLinkAboutCLE201800188 Application 2018-09-18Application for onin Clearance'"`�r JtI r CLE #� OFFICE USE NLY //�� PLEASE REVIEW ALL 3 SHEETS Check # Date: . 2'& 1 Receipt # Staff: "�-- /1 ')/ 1 10, PARCEL INFORMAT ON,A, (� I Tax Map and Parcel: 1,5�yW--W -00—�z4A0 Existing Zoningt u4uV cAeV. S Parcel Owner: Parcel Address: 04-LA 14D Wo �4wv I State (include suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? j ei)� DO ,r Address : l 9L S t ►�,s � City `` I A ij- rA State � 4� Cy l (XI 12!�{aZipLU 73 Office Phone: Cell 460 - U73 Fax # E-mail I UL% CJO APPLICANT INFORMATION Check any that apply: V Change of ownership Change of use Change of name New business Business Name/Type: Previous Business on this site 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: -V-W (C tf\p w �A< j 7 *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 ovt r have the ow er's permission to u e space indicated on this application. I also certify that the information provided s true and accurate to th b st of my kn pledge. I h ad the conditions of approval, and I understand them, and that I will abide by them. Signature Printed \� T� 1 4 ('i-o C_ J APPROVAL INFOR TION 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: 01 Building Official Date 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 2 of Intake to complete the following: Y /Q Is use in LI, HI or PDIP zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y/0 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 pu t;wtnt r? If private well, provide Health form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that appl Is parcel on septic or p lic se r? Y / N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y / N Will there 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: 100 / it SYl rmitted as: , ll Under Section: ( oZJ Supplementary regulations section: Parking formula 1 11i� ati� + Required spaces: Y/N Item o be verified in the field: Inspector: Notes: Date: olations: / N so, List: Proffers: Y / N If so, List: z r�l q rg R-7om)o 7 L I O Z M A ,c �3000v Variance: Y / N If so, List: *59i If S/ LiSt. SOP I el )qq� j�na f`1 1 a U o �— � Rn��x� ttv' i cIG 9 noc� r� I ip I Q el 1 OC'�© Cj 1 o nC Ckt iOGM Clearances: 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, 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]. Sign ture &Applicant ej ) T-41 IQ Gr C- Q Print Applicant Name // � / / _ Date