HomeMy WebLinkAboutCLE201500193 Application 2015-10-26f11 AI
Application for Zoning Clearance
CLE # l°I,3
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check# c&-13\1 Date:
Receipt# 1.01 Al%5 Staff:
PARCEL INFORMATION
Tax Map and Parcel: — S Existing Zoning� � W � �>tn
Parcel Owner: Cc, r Vivi Y-0�'
Parcel Address: /67-1 '4ej.P %+x City l,Fa�— State ✓;- Zip 3A9//
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project?
Address : City.r.! u.� State Zip
Office Phone: -W 3x'7-177SFax # &mail o31r7 &—e!4 447-- -
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business NamerType: _�,�-1 �^ Z -P" CA�0= —4- 99=4 5- `'5f0'
CIZ
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:�T--'
AV -
*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. 11 ha ad the conditions of approval and I understand them, and that I will abide by them.
Signaturd Printed
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions j ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xi 17.
[ ] 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�i.l 1
Zoning Official Date Z-3 ZtS
Other Official Date1i�Z7J S
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 tate following:
Y/N
Is use in LI, Hl or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
Will 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
Reviewer to complete the following:
Square footage of Use:37
6)IN
Permitted as: ''�^
Under Section: _ 2'
Supplementary regulations section:
P k' f mula.
Circle the one that applies
is parcel on private well or ublic r?
I1 -private well, provide Health rt t form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies��
Is parcel on septic 0( ' r?
YIN
Will you be putting u a n� sdn of any kind?
Sign permit. 1-0 ' UU
Permit # �1 l
13 y2.
ar mg or
a0
Required spaces: /`
V o
items to be verified in the field:
If so, obtain proper
Inspector' Date:
Notes:
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # ;—b Mu
Zoining to com fete the following:
Violations:
Y /(9
If so, List:
Proff s:
Y /W
If so, List:
S s'
IN
If so, List:
Var nee:
Y/
If so, List:
SDP's 5
Clearances:
-
Revised 7/1/2011 Page 3 of 3
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
Thisform must accompany zoning applications (Home Occupation, Zoning Clearance, Zoning
ArlministratorDeterminations or Appeals, Sign Permits, Building Permits) if the application is not the
owner.
I certify that notice of the application,
was provided to
[County application name and number]
[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
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].
nature of Applicant
Print icantJName
t'�'/lam/ J�/•!
Date
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF HEALTH
Chicly-Fil-A, Inc
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.
FACILITY NAME: CHICK-FIL-A
PHYSICAL ADDRESS: 1626 Richmond Road
Charlottesville, VA 22901
MAILINGADDRESS. 5200 Buffington Road
Atlanta, GA 30349
EXPIRATION DATE: October 31, 2016
CONDITIONS: ' — A
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.