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Home My WebLink AboutCLE201500028 Legacy Document 2015-03-13C/-Ita Floc) Application for Zonin ClearanceJt�,` . CLE #;t - OFFICE PLEASE REVIEW ALL 3 SHEETS Check # Date: Receipt # Staff: 1 PARCEL INFORMAT% 1 y _ Q !� );xisting Zoning Q1 UOI),, d�l Tax Map and Parcel: �p I n ''f//'i Parcel Owner: NUMO�i�i�J T1�,('� C.�A AP �,�� city state V/'� zip"llaoI Parcel Address: bl 5 ni —NI L�`t 2D (include suite or floor) PRIMARY CONTACT Who should we call/write `concerning this project? �� 4 Address , / Zzi�` I" �W �3 �� Z 7N City l J 1/12 • State �V' Zip : � Office Phone: Cell#�5V(-L��JFax# -71S— B -mail( c1t.P o V i1t; C P?l�.E'rSL- i��tYl. APPLICANT INFORMATION Check t apply: Change of ownersh Business Name/Type: Previous Business on this Describe the proposed business including use, number of vehicles, and any additional information that�ou pan prc n ,C:\ '7)" 1-'\ 1 n _ 111�a.'� a - A - _ � 1 n , Ze e of use Change of name ✓ New business number of shifts, available parking spaces, numbFr of --TT1 i k *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 1 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 accura o the best of my Icno ledge. I have read the conditions of approval, and I understand them, and -that-I will abide by them. Signature cif Printed �r�l,� G�`-' ��1�� ' U APPROVAL INFO TION Denied Approved as propose If' [ ] Approved with conditions [ J [ J 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 site complies with the site plan as of this date. Notes: Building Official Date ;L -(Date Zoning Official Date Other Official County of Albemarle Department of Community Development__ 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 Revised 7/l/201 1 Page 2 of 3 (?•uvV'\ Intake to complete the following: Y /�N) Is us n LI, HI or PDIP zoning? ITso, give applicant a Certified Engineer's Report (CER) packet. Y/N ill 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 oi(public water If private well, provide Heall•th-Deplrtment form. Zoning review can not begin until we receive approval from Health Dept, FAX DATE Circle the one that apple Is parcel on septic o�ublic sewed - Y/N Will you be putting up a new sign of any kind? Sign permit. Permit # �11L1 �%�� LA�� If so, obtain proper Y �N ,Wi'II there be any new construction or renovations? If so, obtain the propePermiX k Permit # �J—jl�I �1 Reviewer to complete the following: Square footage of Use: C)/ N Permitted as: Under Section: 'w - D Supplementary regulations section: Parking formula: Required spaces: Y/N Items to be verified in the field: Inspector : Date: Notes: Zoning to complete the following: viol •ons: If so, ist: Proffers: N Tf so, List: l� SP's: Y /N If so, List: Variance: 6/ N If so, List: SDP's / Clearances: Revised 7/1/2011 Page of CERTIFICATION THAT NOTICE OF THE APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER This form must accompany zoning applications (Nome 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, [County application name and number] was provided to [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 V/ Mailing a copy of the application to r [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 forthatentity] on .L� dent to the following address: Date ,� FfL, oc chrnzm on [address; written notice mailed to the owner at the last known address o he owner as shown on the current real estate tax assessment books or current real estate tax assessment records satisfies this requirement]. Al Signature of A Print Applicant Name 71 Date I I l c ' COMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH CERTIFIES THAT Cavalier Donut Corporation is hereby granted a permit/license to operate as a Full Service Restaurant by the Albemarle County Health Department in accordance with the regulations of the Board of Health, Commonwealth of Virginia. FACILITYNAME: DUCK DONUTS PHYSICAL ADDRESS: 2075 Bond Street Charlottesville, VA 22901 MAILING ADDRESS: 2075 Bond Street, Suite 120 Charlottesville, VA 22901 EXPIRATION DATE: March 31, 2016 Jason Fulton Environmental Health Specialist, Sr. Please direct questions or concerns to the Albemarle County Health Department, Environmental Health Services, (434) 972-6219. This Permit Is NOT TRANSFERABLE From One Individual or Location to Another. I i _ I COMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH CERTIFIES THAT Cavalier Donut Corporation is hereby granted a permit/license to operate as a Fu// Service Restaurant by the Albemarle County Health Department in accordance with the regulations of the Board of Health, Commonwealth of Virginia. FACILITY NAME: DUCK DONUTS PHYSICAL ADDRESS: 2075 Bond Street Charlottesville, VA 22901 MAILING ADDRESS: 2075 Bond Street, Suite 120 Charlottesville, VA 22901 EXPIRATION DATE: March 31, 2016 Jason Fulton Environmental Health Specialist, Sr. Please direct questions or concerns to the Albemarle County Health Department, Environmental Health Services, (434) 972-6219. This Permit Is NOT TRANSFERABLE From One Individual or Location to Another.