HomeMy WebLinkAboutCLE201300090 Legacy Document 2013-05-13�1eun�4
Application for Zoning Clearance
CLE # V) 616
1' /IiCll:`�F
PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # IJ L 6 Date: 2 a
Receipt # Staff;
PARCEL INFORMATION
2n
�2 - '✓W L Existing Zonin V,
Tax Map and Parcel;
U �W' yvn r W
Parcel Owner:
i�m-h � i n Cit 1� � 1 tate �(A Zip
Parcel Address: � Y
(include suite or floor)
PRIMARY CONTACT ( �`'S
Who should we call/write concerning this project. �/
Address: %,s 2 -2 S Pr„ //r``% 6d v" -�- City 66,16 vv r < i State 10ji Zip 22 0
Office Phone: (q) e 3 Cell # e7 v 61116 Fax # E -mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
q �
�1/t- � w'�� " ' G ' O
Business Name /Type; 1�
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:
*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 best of ns of approval, and I understand them, and that I will abide by them.
=Printed 'ti�`'y r �
Signature
APPROVAL INFORMATION
as proposed [ ] Approved with conditions [ ] Denied
?fApproved
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. • I
[ ] This site complies with the site plan as of this date.
Notes:
Building Official � �— Date
Zoning Official �'�/ Date 3111 /3
Other Official Date
County 01 AiDemarie "epartmenL ui t,uni mumuy 1jov ctvvi—Li �
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
0 e a
V
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a
Engineer's Report (CER) packet.
Y/N
Will there be food preparation?
If so, give applicant a Health Department for .
Zoning review can not begin until we recei a approval from Health
Dept, FAX DATE
Circle the one that applies
Is parcel on private well or public ater?
If private well, provide Health D artment form.
Reviewer to complete the following:
Square footage of Use:
N.
Permitted as: u.1/
Under Section:-4-S-= _ A J e,
Supplementary regulations section:
Parking formula:
Zoning review can not begin u .til we receive approval from Health Required spaces:
Dept. FAX DATE
Y/
Circle the one that applie Itemh6 be verified in the field:
Is parcel on septic or p lie sewer?
Y/N
Will you be putt'}g up a new sign of any kind? If so, obtain proper
Sign permit. / Inspector : Date:
Permit # /
Y/N
Will ther be any new construction or renovations?
If so, o - tain the proper Permit.
M
---- i_1._ eL_ r- It —
Notes:
l�V11111 LV LiV111 1V4V 411V 1V11V 1111
Violations:
Y /INK"
Ifs , L/:st:
Proffers:
Y/t
If so, st:
Variances:
Y / ,lCl,/
If so, st:
SP's:
Y Y�I
if , st;
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
P
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Horne 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:
the owner of record of Tax Map
by delivering a copy of the application in the
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
[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 to the following address:
Date
[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
�z�y;Lf1�R
E PENDENT
I Charlottesville Holiday Tradition since 1983"
Hosted by
Kiwanis Club of Charlottesville and Charlottesville Track Club
To Benefit Camp Holiday Trails elo
)ver $100,000 has been donated to this charity over the years!,
Race time is Wednesday, July 4, 2012 at 7 :30 a.m
0% %IN= Forest lakes N ®rtit Subdivisi ®n® F ®ll ®VV signs tr ®C<n R ®life 24 NOY9 boil.
* * * * * Registrati ®n information
$25 CTC members, $26 non -CTC members, $20 Students, $30 all entries race day at 7:30 a.m.
Please make checks payable to: Kiwanis Club of Charlottesville
Mail to : Kiwanis Club, 925 Dorchester Place #303, Charlottesville, VA 22911 prior to June 30th
Or hand - deliver to: Ragged Mountain Running Shop prior to 5:00 p.m. July 2nd
Or Register online at http : / /charlottesvilletrackciub.org
Race day registration begins at 6 :30 A.M. at Lighthouse Worship + family Center (3460 Worth Crossing), near the start line
Award categories for all age groups, including the youngsters(,® & younger)!
"My 4th ofluly experience has been enriched over the years thanks to this wonderful community event."
Mark LorenPoni
FOR MORE INFORMATION CALL 434.293.3367 (WORKDAYS) OR 434.244.2909 (NIGHTS)
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Last Name
Andress
State Zip
Daytime Phone
First
City
E -Mail (Optional)
Age on race day Sex T -Shirt Size Child S M L XL 2XL CTC Member Y N
LIABILITY WAIVER MUST BE SIGNED
I know that running a road race is a potentially hazardous activity, l should not enter and run unless i am medically able and properly trained. I agree to abide by all
decisions of the race officials relative to my obflty to complete the run safely. I assume all risks associated with running in this event, Including, but not limited to,
falls, contact with other participants, the effects of weather, including high heat and humidity, traffic and the conditions of the road, all such risks being known and
appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my
behalf, waive and release the Kiwanis Club of Charlottesville, the Charlottesville Track Club, Forest Lakes Community Association, the County of Albemarle, all
beneficiaries, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event.
Furthermore, I agree to be bound by the rules established with respect to this event In consideration of the safety of all participants, I understand that absolutely
no baby joggers, baby strollers, headphones, animals on leash, skateboard, skates, roller blades or bicycles are _allowed ,on the course. In addition, I understand
that if the race is canceled by circumstances beyond the control of the organizers, my entry fee will not be refunded.
SIGNATURE (parent or guardian, if under 18) Date
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Denotes
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a
Traffic control required or as directed by Albemarle County Police
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x
Rt. 541
a
Traffic control required or as directed by Albemarle County Police