HomeMy WebLinkAboutCLE201600012 Application 2016-03-28A
Application for Zoning Clearance
CLE #Gl
OFFICE USF&ONLY All
PLEASE REVIEW ALL 3 SHEETS Check4 C1B Date:
Receipt # fJ Staff';
PARCEL INFORMATION
Tax Map and Parcel: & / - /,;?- ;3 Existing Zoning�-
Parcel Owner: i0v /'0 •}/� 7�iPA./
Parcel Address: 4/0 D " city 4�awlb State �� zip X3'2
(include suite or floor)
PRIMARY CONTACT I }�
Who should we call/write concerning this project? IW %
Addresa :: (D/ G� �/�% �.� �1city��t�I��y� ViL State �i Zip
Office Phone: C__) Cell � ` �' .y max # E-mail
APPLICANT
Check any that apply: A— Change of ownership Change of use _
Business Name/Type: -0 7-10 A 19 I%V �__ — 64y pr
G
9�
of name New business
Previous Business on this site Ae)
Describe the proposed business including use, number of employees, number of #t�, available parking spaceg, number of
vehicles, and any additional information that you can provide: LAG /om
'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 1 o e own pe slo use the space indicated on this application. I also certify that the information provided
is true and accura o est of kno age. I h nditions of approval, and I understand them, and that I will abide by them.
Signature Printed 4-/-11? / s % �1711a /Z- e— cs,,y i
APPROVAL INFORMATION
[ pproved as proposed [ ] Approved with conditions [ J Denied
[ J 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 site plan as of this date.
Notes:
Building Official Date L
Zoning Official G Date �%
Other Oficialall Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 295-5832 Fax: (434) 972-4126
Revised 11/1/2015 Page 2 of
Intake to complete the following:
Y/O
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
'Y / N
Nill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we receive apprpval from Health
Dept. FAX DATE PT
I# 6�
Reviewer to complete the following:
Square footage of Use: 'J v L)
0/N
Permitted as:
Under Section: _ ZS, !
Supplementary regulations section:
Circle the o'i�e that les t�Nia
&�,(,Q Parking formula: �r 7-5
Is parcel on private well or ublic orate f� J a��
If private well, provide Heal ep ent form.
Zoning review can not begin until we receive approval from Health Required spaces:
Dept. FAX DATE
Circle the one thatappl'
Is parcel on septic or ublic sewer?
Y 0
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
YI
ItemsYo be verified in the field:
If so, obtain proper
Inspector : Date:
Y I@ Notes:
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
f , . :
Zoning to complete the following:
Viola "ons:
Pro rs:
Y/V
Y/
If so, List:
If so, List:
Variance:Is:
4i/N
6/N
If so, List:
If so, List: g
Clearances:
SDP's
Revised 11/1/2015 Page 3 of
ill
CERTIFICATION THAT NOTICE OF THE
APPLICATION HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning applications (Home occupation, Zoning aearance, Zoning
Administrator Determinations or Appeals, Sign Permits, Building Permits) if the appikation is not the
owner.
I certify that notice of the application,
[County application name and num1xr]
was provided to J 7 M//,f-the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number &/ " / 2 -1 by delivering a copy of the application in the
manner identified below:
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 A4 ig O/✓ / �r� / /��
[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 - I -A- �`+t �j "'`� to the following address:
Date
7/1 3 S 7-,q,PL. t f L
Inuumss; written notice mailed to the owner at the last known address of the owner as shofvn on
the current real estate tax assessment books or current real estate tax assessment records satisfies
this requirement].
Signature of Aplicant
Print Applicant Name
Date
iWM �-- �-
R�outine P /Vuv d aw,'Kt-
of i o weal oglnia Page 1 of
z0 Follow up Virginia Department of Health ed
O Complaint Foodservice Establishment Inspection Report Yes
® other 2
® Critical Items Exempt p
Est. Name: I 11 A .Address: �OeQ4 10IJ
Date: 1/ /–/ . Tune in: — — Time out: 53P &044,
Allotentiall
p y h: ous foods (PHF) must satisfy safe temperature requirements during storage, preparation, display,
service and transportation. Such safe temperatures include: Cooping poultry 2!:165'F; Cooling ground beef >_155° F
Cooking pork ?145°F; Reheating a PHF rapidly to X165°F;
Hot_ holding 2140°F; a d, Cold t 41 r below. C'
The following temperatures were observed: —A
VAC Section
12 VAC 5-421-
Descriptions 1 Remarks 1 Corrections
F4 14JIi r)
- .fir e
Thed observations, vio�taons an sun s pen o e for ons are �ssu iuu actor ceto r
Food Regulations. It is the responsibility of the permit holder oto comply with directives o e regulatory authority including time frames
for corrective actions..." An opportunity for a hearing on the inspection results, a time limit, or both, shall be granted provided that a
written request is filed with the local health department within 30 days following the inspection report, A f now --up inspection to assess
your correction of thesp�ola may be conducted on, or about, '20
Received .
by: En Health Specialist: 44e r
r � � EHS-152 )
its, a� 5,�