HomeMy WebLinkAboutCLE201400055 Legacy Document 2014-05-05b ,
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Application for Zoning Clearance
CLE # 2-014-
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OFFICE USE ON
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: c J 2 L 3& L Existing Zoning
Parcel Owner:
Parcel Address: ww Crt l A( 1c) State /A Zip22q I
(include suite or floor)
PRIMARY CONTACT
Who should we call /writes this project?
,concerning�
�1W��1/1/ 1 , t/ I ` U, = City �l 1� to Zip 2 l�
Address :
Office Phone: L) gE) - Oq Cell # 53 `1o1 t'O Fax # E -mail MW V-12 al ly-mgY,
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use _Change of name New business
�� �� Aid �'n P �Q `' 9
Business Name /Type: a�
I
Previous Business on this site �.J'1/i% i j Or) o 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:
*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 a est o ]eddge .II ve read the conditions of approval, and I understand them, and that II will abide by them.
-
�s "" Printed IAA �J(FX,t
Signature'
APP AL 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 si e complies with the site plan as f this date. n
/✓ ��
Notes
Building Official Date
Zoning Official Date 10) /
Other Official Date
County of Albemarle Department of uommunny Levelulnneui
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 972 -4126
Revised 7/1/2011 Page 2 of 3
U
y �a
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applica a Certified
Engineer's Report (CER) packet.
Y/N
Will there be food preparation?
If so, give applicant a Health Department
Zoning review can not begin until we re
Dept. FAX DATE
Parking formula: f
. water? �i
Circle the one that applies
Is parcel on private well or pu
If private well, provide Health
Zoning review can not begin
Dept. FAX DATE
Circle the one that appl
Is parcel on septic or p
Reviewer to complete the following:
Square footage of Use:
pitted as: aw)
Under Section
ve approval from Health I Supplementary regulations section:
)artment form.
we receive approval from Health Required spaces:
Yr
Item to be verified in the field:
sewer?
Y/N
Will you be putt' g up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/IN
Wilbe any new construction or renovations?
If son the proper Permit.
Per
0 q110
Inspector :
Notes:
Date:
uv as aaa
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
Commonwealth of Virginia
Department of Transportation
7/2010
L11 a Ly � / Z-1
kP-PkbVAL1DATE
Remarks:
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LUP -SEA
LAND USE PERMIT
Special Events
Approval Form
ADMINISTRATOR / T9)WN MANAGER�OR DESIGNEE
_April 16, 2014 Sergeant Miller Stoddard
APPROVAL DATE LOCAL LAW ENFORCEMENT AGENCY
Remarks: The Albemarle County Police Department approves of this race and event. This event has a long and safe
history in Albemarle County. I, Sgt Stoddard, have no traffic safety or public safety concerns about the race.
APPROVAL DATE VIRGINIA STATE POLICE (Sergeant /Area/Division)
Remarks:
APPROVAL DATE
VDOT REPRESENTATIVE
Remarks (include any changes that may be made by VDOT):
Cc: County /Town Administration
Local Law Enforcement
Virginia State Police
VDOT Maintenance Residency Office / AHQ
WHEN: Friday, July 4, 2014, at 7:30 a.m. WHERE: Forest Lakes North Subdivision (Follow signs from Route 29 North)
Sponsored by BETTER and Hosted by Kiwanis Club of Charlottesville and Charlottesville Track Club
LIVINGI
To Benefit Camp Holiday Trails
Over $115,000 has been donated to this charity over the years!
------------------ REGISTRATIONINFORMATION ------------- - - ----
Fee: $25 CTC members, $26 non -CTC members, $20 Students, $30 all race day entries
Please make checks payable to: Kiwanis Club of Charlottesville
4 Ways to Register:
By Mail, prior to June 30: Kiwanis Club, 925 Dorchester Place #303, Charlottesville, VA 22911
Hand - Deliver, by 5 p.m. on July 2: Ragged Mountain Running Shop
Online: http : / /charlottesvilletrackclub.org
In- Person on Race Day, 6:30 a.m.: Lighthouse Worship Center, 3460 Worth Crossing, near the start line
Award categories for all age groups, including the youngsters (10 & younger)!
wy 4th of July experience has been enriched over the years, thanks to this wonderful community event. " N Mark Lorenzoni
For more information, call: 434.293.3367 (daytime, Mon -Fri) or 434.244.2909 (evenings)
Last Name:
Address:
State: Zip: Daytime Phone:
First Name:
City:
Email (optional):
Age on Race Day: Sex: M F 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. I 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 ability 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:
f. A
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Denotes Traffic control required cvr as directed by Albemarle County Police