HomeMy WebLinkAboutCLE201500260 Application 2015-12-30Application for Zoning Clearance
CLE# OkS- 06
� A
OFFICE USE Q�p�.Y
PLEASE REVIEW ALL 3 SHEETS Check # 'S(D I Date:
Receipt # JoaLA90 Staff:
PARCEL INFORMATIO
Tax Map and Parcel: �j LA . ` Existing Zoning V C
Parcel Owner: ix) F A i�
Parcel Address:�k� L NI I N'o U—z 7 R�� City E� i. p I t s tate V r t; N i Ia
zip xi I',
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? M l [ "zL` _ L, k -> A
Address : t-�`„ l_r- B1A4:N i �i Si j�j,lC�r111 "�^ City'LhV.W111 v k Ll: State
ZipZ,
Office Phone: Cell #454- e #
APPLICANT INFORMATION
Check any that apply: _ Change of ownership Change of use Change of name New business
Business Name/Type: M Pz`, -� 1 \N G `.1- � L `...1 �; C1 RFS i A X P— N N
Previous Business on this site ►'1 !':'' i N� LL
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, nnmber of
vehicles, and any additional information that you can provide: acv}a Y °fit. ,cva �1 at s Y S4 ► '
lAh- `tam ► ' t1- = _, ° , j&0 et,s
*This Clokadee will only be valid on the parcel for which it is approved. If you change, intenft 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 cer4ify that the information provided
is true and acto best of ledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature F
Printed
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[ ]
Backflow prevention device and/or current test data needed for this site. Contact ACSA, 9774511, 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 _ I I l i o t cS
Zoning Official Date lZ L2
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 9724126
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Reviewer to complete the following:
WY / Square footage of Use: 13 bb
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified '
Engineer's Report (CER) packet. jo / N
r Permitted as: '
YIN
ill there be food preparation? Under Section: Ze
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
Is parcel on private well or ubkhc 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, ublic sewer?
Y
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper I
Y
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followint=:
Parking formula: /xj
Required spaces: /
\ _
/61
Items to be verified in the field:
Inspector;
Notes:
Date:
Violations:
Y /6 ,
If so, List:
Proffers:
Y /M
If so, ist:
Va ' nce:
YlIN
If so, List:
pis;
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,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
the owner of record of Tax Map
by delivering a copy of the application in the
[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 y 3k)cA
[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 enti ]
on 10 to the following address:
Date
'P a,01,u1"l LtC . .6 eYZ rCM A'4`' -PS, ft1ARF 0.2G:3u i �-LE ;�A 22`10
[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].
L/I
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91gnatuure of A licant
I l C_rw
Print Applicant Name
1Z ,?/Zd1�5
Date
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Purl'°se' ommonwealth of Virginia Page 1 of _/
OO outine g
ollow-up�� D rginia Department of Health f
OO Complaint Certified Manage:
Foodservice Establishment Inspection Report Yes p
® Other
OO Critical Items No
" O
3
Est. Name: ��.�;
Date://
Tune in:
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Tune out:1'
All potentially hazardous foods (PHF) must satisfy safe temperature requirements during storage!!, Preparation, display,
service and transportation. Such safe temperatures include: Cooking poultry X165°F; Cooking ground beef 2:1550 F;
Cooking pork 2:1450F; Reheating a PHF rapidly to >165°F;
Hot holding >18nov- s.nrJ .ear . .
The following temperatures were observed:
Food Regulations. It is a —uou u. uwuruiunce wl7tne -
ermlt older °to comply with directives of the regulatory authority including time frames
for corrective actions..." An opportunity for a heariing on the inspection results, a time limit, or both, shall be granted provided that a
written request is filed with the Jaen] 110-511+11 rlana.hrr.o..s:n A ---
your
,._ your correctiol
Received by: