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Home My WebLink AboutCLE201500185 Application 2015-10-19Application for Zoning Clearance ' '_" ``� CLE # ® V5 ' �;� z„,:: I ��rc,ly\P OFFICE USE ONLY PLEASE REVIEW ALL 3 SHEETS Check # K5 Date: 6 �� Receia�pt # Staff: "- PARCEL INFORMATION ff Tax Map and Parcel: O'7'' 000000D 0'b V Existing Zoning Cohn rci�l ParcclOwner; e►i. S �n• ��<< �-�-'�' Parcel Address: 3R4 -'1%A.S 60-ter City e�.Mr 1a��a�r 11r State yA Zip 7-29%1 (include suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? IY �q l m E%I.K- Address : ILSS rreyt,Lktse Q;Ije City G } VIAr State VA Zip 2Tt_>_'L Office Phone: C%4t4 —NU Cell # Fax # E-mail o CDreAVT. •t,/ APPLICANT INFORMATION Check any that apply: Change of ownership Change of use Change of name New business Business Name/Type: L :'}4 6, qsctI S T i 2,Z.- '- InWv -11 't 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: +%,he a.-N mh3 a 10-1-S k-k-% ewVL�S cs j1-; -F#s ; e. %a *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. 1 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 knowle I have read the conditions of approval, and I understand` them, and that I will abide by them. Signature Printed Mn:-*I” APPROVAL 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. [ j 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 —t I V Zoning Official Date Other Official 9D Date. /dh7-c�� County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5$32 Fax: (434) 972-4126 Revised 7/I/2011 Page 2 of 3 Intake to complete the following: Y (@ Is use in Ll, HI or PDIP zoning? Engineer's Report (CER) packet. If so, give applicant a Certified Reviewer to complete the following: Square footage of Use: a ®/ N Permitted as: Y N ill there be food preparation? ki Under Section:—fir If so, give applicant a Health Department form. Zoning review can not begin until we receive approval from Health Supplementary regulations section: Dept. FAX DATE Circle the one that applies �� Parking formula: fv Is parcel on private well ublic water? ,1 �'�J - If private well, provide Healt epa ent form. Zoning review can not begin until we receive approval from Health Required spaces: f* Dept. FAX DATE YI Circle the one that applies Items to be verified in the field: Is parcel on septic or u lic sewer? YIN ill you be putting up a new sign of any kind? If so, obtain proper Sign pe Permit # Inspector : Date: Notes: Y/N Will there be any new construction orenovation If so, obtain the proper Permit. Permit#/ $ZO,S Zoning to complete the followin Violations: (�� Proffers: 'Tf / N List; If so,—List:f so, �g ariance: SP's: O/N /N If so, List: If so, List: 4n •-• Clearances: SDP's bey _-33 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, 32a1 S ^ �-a3y A(— [County application name and number] was provided to v.A s S cr -k"r LL G the owner of record of Tax Map [name(s) of the record owners of the parcel] and Parcel Number 0'7 TV o0oz,040 l^I by delivering a copy of the application in the manner identified below: -A- Hand delivering a copy of the application to krls}:n TpUlv, 61%%A 5%A NtWAR cr [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 q 10 lS 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]. Signature o Applicant Print Applicant Name aj fie j` S Date r Q i x w � � N E�e�aV5 z cn¢Uus r NM U)CD LL LL LL LL LL LL 00 NCQ N co C Z� < W LU 070�tif�V Oa NN�uJRD FOC �r �r E U � v N d EgHca Z<mm¢6Gc rt.. CVT- NM ab6 66 do N N N Na to 1 1 .- �a PagedPof Thomas Jefferson Health District 1136 Rose Hill Dr. VIRGINIA PO Boz 7546 V1 D9 DEPARTMENT Phone 434-972-6219 OF HEALTH PYokd*g You and row l%harrnrerrf Establishment Name Address Food Product Food Flow Step Temp Food Product Fvod Flow Step Food Product Food Flow Stop Equi ment Temp \, + k-% �4 Unless otherwise specified in this report, risk factor and intervention violations shall be corrected at the time of the inspection and good retail practice violations shall be corrected no later than 90 calendar days after the date of this inspection. Any instructions listed under °comments" shall be complied with as specified. Failure to comply with the time limits for corrections specified in this report may result in suspension and/or revocation of the food establishment permit. An opportunity for a hearing on the inspection observations, violations, and/or specified correction actions will be provided if a written request for a hearing is Tiled with the Director of Health by the permit holder within 30 days of the date of this report. For further information on the appeal process, please call the Thomas Jefferson Health District, Food Safety Team at (434) 972-6219 Code Section V ,V . f' Person in Charge Sl nature i'►,,,.�`r Date Environmental Health Specialist (Signature) ;- . •�s .,._��— - • „9,0