HomeMy WebLinkAboutCLE201500015 Application 2015-07-27Application for Zoning Clearance''
CLE # 2015-15
; . a,;�
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: 02600-00-00-05700 Existing Zoning land us
Parcel Owner: Bradford and Rebecca Cogan
Parcel Address: 5275 Sugar Hollow Rd. City White Hall State VA Zip 22987
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Victoria Brunjes
Address :2200 Rocky Run City Charlottesville State VA Zip 22901
Office Phone: ±34 296-8539 Cell # Fax # E-mail
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: White Hall Ruritan Club/ non-profit Community Service organization
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:
A 5K/1 OK run up & back on Suaar Hollow Rd March 14 2015. Parking will be on private land with owners permission.
Run is sponsored by White Hall Ruritan Club as fundraiser for Community Building renovations.
*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 I understand them, and that I -Will abide by them.
Signature_ r i A t 7 s� til ��M i1 �, Printed /1'e-41ris. L /5/`r&� Ps
APP VAL INF' TION
pproved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. ContactACSA, 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 sitt complies vaith;the site plan as of this date.
►i .Official T— Date i % G
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 7/1/2011 Page 2 of 3
Intake to complete the following:
Y/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
Wil re 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 public water?
If private well, provide 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 septic or public sewer?
Y /�:)
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y4ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
7.nninto rrmmnlata 1 -hp fnllnwina-
Reviewer to complete the following:
Square footage of Use:
Y/N
Permitted as:
Under Section:
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector
Notes:
Date:
Violations:
Y/N
If so, List:
Proffers:
Y/N
If so, List:
Variance:
Y/N
If so, List:
SP's: ar s
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 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, (A �i ea tis- �C �� h i A �wGt mei A c2
/� P /� [County application name a number]
was provided to �lJ r -C, c, I,— the owner of record of Tax Map
[name(s) of the rec&d owners of the parcel]
and Parcel Number 6 ,J �, c)o -n o - c� a o oo by delivering a copy of the application in the
manner identified below:
_',L4 Hand delivering a copy of the application to 6j--1
[Name of the recoiVowner 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 1 — ;20 - I
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].
L174-4 -,, A � A
Signature of Applic
V, ,�br 1L
Print Applicant Name
I— o)o
Date
S
Common`vYealtu Of Vir g'ili1a LTJP-A
Department of Transportation LAND USE PERMIT APPLICATION
3/2010 P.O. Box 1017, Troy, VA 22974
434-559-1013
APPLICATION is hereby made for permit as shown on the accompanying plan or sketch and as described below. Said activity(s)will be done under and in accordance with the rules and
regulations of the Commonwealth Transportation Board of Virginia, in so far as said Hiles are applicable thereto and any agreement between the parties herein before referred to. Where
applicable agreements may be attached and made a part of the permit assembly including any cost responsibilities covering work under permit. Applicant agrees to maintain work in a
manner as approved upon its completion. Applicant also hereby agrees and is bound and held responsible to the owner for any and all damages to any other installations already in place as a
result of work covered by resulting permit. Applicants to whom permits are issued shall at all times indemnify and save harmless the Commonwealth Transportation Board members of the
Board, the Commonwealth and all Commonwealth employees, agents, and offices, from responsibility, damage, or liability arising from the exercise of the privileges granted in such pemrit
to the extent allowed by law. In consideration of the issuance of a permit the applicant agrees to waive for itself, successors in interest or assigns any entitlements it may otherwise have or
have hereafter under the Uniform Relocation and Assistant Act of 1972 as amended in event the Department or its successor, chooses to exercise its acknowledged right to demand or cause
the removal of any or all fixtures, personality of whatever kind or description that may hereafter be located, should this application be approved.
TYPE OR PRINT CLEARLY
DL Number or Tax ID number 17053322373013 Contact Name Victoria Brunjes
Owner Name White Hall Ruritan Club E-mail Address _vbrunjes@gmail.com
Address _PO Box 294, 2094 Browns Gap Turnpike Phone Number ( _434_) _296-8539
City _Crozet State VA—Zip Code Emergency Number ( 434- ) 296-8539
Fax Number ( ) -
DL or Tax ID number Contact Name
Agent Name E-mail Address
Address Phone Number ( ) -
City State Zip Code Emergency Number ( )
Fax Number ( )
Permit Term Requested Fees Enclosed $ Check Number Coupon Number(s)
Money Order Other Estimated cost of work to be performed on VDOT Right of Way $
Surety Information: Surety Company Name
Amount of Surety $ Obligation Amount $
The Surety posted by Owner ( ) or Agent ( )
Check # Bond # ILC #
Surety Refunds paid to Owner ( ) or Agent( )
[ ] Corporate Surety [ ] Resolution [ ] Ordinance [ ] Waived
Applicant has provided proof of the following requirements in accordance as defined in Code of Virginia section 2.2-1151.1.
(1) The utility company has registered as an operator with the appropriate notification center.
(2) Attached is a notarized affidavit, that the utility owner has notified the commercial and residential developer, owner of commercial or multifamily real
estate, or local government entities with a property interest in any parcel of land located adjacent to the property over which the land use is being requested, that
application for the permit has been made.
Request Permission: To perform the following activity(s) _To hold 5K/1 OK run on Sugar Hollow Road on March
14, 2015, beginning at 8 a.m.. We will not be stopping traffic, but will be notifying all households along
the route at least a week before the race. Race will begin near 5275 Sugar Hollow Road, with parking
on private land near start line. Course is and out and back track. Signs will be posted at either end of
Sugar Hollow Road, and near the south end of Sugar Ridge Rd. There will be volunteers posted near
Sugar Ridge Rd. intersection to alert entering traffic to presence of runners. We expect less than 200
runners, probably less than 100.
as per attached plans.
Location: Tax Map Number Applicant Job No.
Geographically in County / Town / City of White Hall , On Highway Route and /or Name—Sugar Hollow Road
Between Route St. Name Latitude Longitude
And Route St. Name Latitude Longitude—
[ 1 IF APPLICABLE, I AGREE TO PAY THE FULL SALARY AND EXPENSES OF A STATE ASSIGNED INSPECTOR IN �/ /
CONJUNCTION WITH THIS PROJECT, COVERED BY ACCOUNT RECEIVABLE NUMBER. . f ju" �G.&
Signature of applicant ;l i C%ia2 r - -1� ;�1 1 Title pt v, �,� Date
Signature of agent t% Title Date
All applicable items on this form must be completed before your request can be considered. Recheck information furnished to avoid delay. Prepayment
Required - make Remittance payable to Virginia Department of Transportation. Permit office telephone number: 434-589-1013, Zion Crossroads, VA
VDOT USE ONLY
Receipt is hereby acknowledged of CHECK COUPON M.O.
In The Amount of $
Permit Fee $ Cash Surety $ VDOT Reference Number
Signed VDOT.
2013 Special Events Check List
Your permit will be reviewed for approval as submitted under the following conditions:
• Traffic and Race Control must be coordinated with and under the direct supervision of the
Sheriff's Department for your locality. Provide a copy of the written Agreement.
• Certified Flaggers with vests are to be posted at intersections as determined by the Sheriff's
Department. Flagmen Ahead and Be Prepared to Stop Signs should be used at any intersection
controlled by flag personnel or County Police.
• Control the run area with barrels or cones
• ***Emergency Vehicles Must be Able to and Allowed to Pass***
• The following are to be notified of the Special Event/Race: Local Post Office and Emergency
Services or others as directed by the Sheriff's Office.
• Five days prior to the event Announcements must be made by the Local Media indicating the
time and location of the event in order for local residents to plan accordingly.
• The Routes should be policed for trash and debris at the conclusion of event and disposed of
properly.
• Keep your permit on site for the entire event
Persons to whom permits or permissions are granted shall at all times indemnify and save harmless the
Commonwealth Transportation Board, members of the board, the Commonwealth of Virginia and all
Commonwealth employees, agents and officers from responsibility, damage or liability of the privileges
granted in such permits or permission.
It must be understood that the permittee will adhere to all the contingencies as stated above.
zz '-/ . &.'�_1/20/15
Signature of Eve 610ordinator/Pefmit Applicant Date
_Sugar Hollow Bridges Run 5k/10k
Event Name
Commonwealth of Virginia LUP-SP
Department of Transportationa) LAND USE PERMIT
3/2010 Special Provisions
NOTICE OF PERMITTEE LIABILITY
Permittee Agreement for Land Use Permit Issuance
I the undersigned applicant hereby acknowledge that I am fully cognizant of all of the following requirements
associated with the issuance of a VDOT LandUsePermit.
Applicant Name: 1/t, -Arta,- L G� {r �!yl l P C
Applicant
Project Name:
Route Number:— County11110ALe- 1.0 Residency:VA
Any of the following provisions that may apply, shall apply:
Permittee acceptance and use of a Virginia Department of Transportation (VDOT) Land Use Permit is prima
facie evidence that the permittee has read and is fully cognizant of all required permit provisions, applicable
traffic control plans and associated construction standards to be employed. ALL applicants to whom permits
are issued shall at all times indemnify and save harmless the Commonwealth Transportation Board, members
of the Board, the Commonwealth, and all Commonwealth employees, agents, and officers, from responsibility,
damage, or liability arising from the exercise of the privileges granted in such permit to the extent allowed by
law.
2. The permittee agrees to secure and carry insurance against liability for personal injury and property damage that
may arise from the work performed under permit and/or from the operation of permitted activity -up to one
million dollars ($ 1,000,000) each occurrence to protect the Board members and the Department's agents or
employees; seventy-five thousand dollars ($75,000) each occurrence to protect the Board, the Department, or
the Commonwealth in event of suit.
3. The permittee assumes full responsibility for any and all (downstream flooding, erosion, siltation, etc.) damages
that may occur as a result of the work performed under this permit. Furthermore, the Department will in no
way be responsible for any damage to the facility being placed as a result of future maintenance or construction
activities performed by the Department.
4. The permittee agrees to move, remove, alter, or change any installation that interferes with the ultimate
construction of the highway in alignment or grade at NO cost to the Department unless otherwise stipulated and
agreed to by the Department.
5. The permittee shall immediately correct any situation that may arise as a result of these activities that the
District Administrator's designee deems hazardous to the traveling public.
6. Any and all highway signs, right-of-way markers, etc., disturbed as a result of work performed under this permit
shall be accurately reset by the permittee immediately following the work in the vicinity of the disturbed
facility. The services of a certified land surveyor with experience in route surveying may be required.
7. It shall be the permittee's responsibility to obtain ANY and ALL necessary permits that may be required by any
other government agencies, i.e., U.S. Army Corp. of Engineers, Department of Environmental Quality,
Department of Conservation and Recreation, etc.