HomeMy WebLinkAboutCLE201500045 Application 2015-04-241� -. 45
Application for Zonin Clearance
CLE #
OFFICE USE ONLY(
PLEASE REVIEW ALL 3 SHE Checic # _ j v
Receipt # taff. L
PARCEL INFORMATION
Tax Map and Parcel:o �!Z-' b t = Existing Zoninu
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Parcel Owner: T �t9t1�f -�"✓1 �G✓ 7't C . , J
? X60 c'- 1 had ,,�ie� VI � State V � zip 2,29//
Parcel Address: (Nd T'T 11 ��75� �'�4 City � ��9 � � �rl�
(include suite or floor)
PRIMARY CONTACT r�
Who should we call/write concerning this project? u it S
Address :,
5 �Cr �V,rry 1�r` t Co �✓ 7 - City C t+usrc�SVi`Ilr State �' Zip
(¢� ) Cell # '3 %/; Fax # E-mail s�i'J 11w17,cvl��I6°�
Office Phone: /
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: 3 ?_J A ttn uc•.!
� f -Je° P("�'�`� Cir. GG' Pa Sk i^''
Previous Business on this site '� U th A wl cYs
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 to the best of my knowledge. I have read the conditions of approval, and
^II understand them, an/d� that I will abide by them.
Printe
Signature d Y "r � Ct�w� 7 • J`/ ct S
AP` OVAL INFORMATION Approved with conditions Denied
[ Approved as proposed [ ][ ]
[ ] 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 Bite plan as of is date. 0 6 /A✓�� �. ��
Notes:__- AUL f �1Mf A Irr
Building Official
Zoning Official
Other Official
Date 3 Ft l
\uC 5
� Date
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fnx: (434) 972-4126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following: Reviewer to complete the following:
Y ! N Square footage of Use:
Is use in LI, HI or PDIP zoning? If so, give applicant aCertified/ N
Engineer's Report (CBR) packet. n
rmAll rf-
itted as• U r
Y / N
Will there be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section: 1
Dept. FAX DATE
Circle the one that applies Parking formula, t 2 n r
J Z(Ji�
Is parcel on private well or publie'water?
If private well, provide Health Department form.
Zoning review can not begin until we receive approval from Health Required spaces;
Dept. FAX DATE i Y / N
Circle the one that applies'
Ito be verified in the field; 1
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. .I
Permit #
Y/N //
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followin :
Viol r s:
YIN
Ifs st:
Var, cc;
If/
Ifs , i-st�
T
Ib
Clearances. I�
•t
Proffers:
Y/N
If so, List:
's.
Y/ N
sa, List
SDP's
Revised 7/1/2011 Page 3 of 3
E-1
Itt•f7Zl TimberwoodBlvd
16
fracas pipJ.
Rt. 649
Denotes Traffic control required or as directed by Albemarle County Police
WHEN: Saturday, July 4, 2015, 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
LAvllrG
To Benefit Camp Holiday Trails
Over .$120, 000 has been donated to this charity over the years!
------------------- REGISTRATION INFORMATION ------------------
Fee: $25 CTC members, $26 non -CTC members, $20 Students, $30 all race day entries
Please make checks payable to; K!wan!s 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)!
"My 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: First Name:
Address:
State: Zip: Daytime Phone:
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: