HomeMy WebLinkAboutCLE201700032 Application 2017-03-29Application for Zoning Clearance"
CLE #20
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OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check # Date:
Receipt # Staff: JK
PARCEL INFORMATION (5c5 I
Tax Map and Parcel: v ! Existing Zoning � urcd
Parcel Owner:
Parcel Address: State Zipa/✓
(include suite or floor)
PRIMARY CONTACT item S�-�
Who should we call/write concerning this project?
Address : "' City ` State / ' Zi2—V
Office Phone: Celr4 l t5 a # E_ it
ec� 1 t4VA0
APPLICANT INFORM ION
Check any that apply: Change of ownership Change of use Change of name New business
Previous Business on this site
/C) 'rc_ 1 13
Describe the proposed business including use, number of employees, num¢e-r of shifts, available parking seaces, nu ber of
vehicles, and any additional infornlation that you can wrovide: lip/�-�(/�1 //I n -1� �/,�,.L /_ _/ r. f.
*This Clearance will only-l5e 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 t best 91
my knowledge. I have ad the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed t�? — & — / 7
VAL INFORMATION
[ WApproved as proposed [ ] Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x] 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 s plies with sit, 0-- as o this � date. } 1
Notes: -�,/) 1Cdr h d t
Building Official
Zoning Official
Other Official
Date
Date 01 15 I
Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
UR
Revised I1/1/2015 Page 2 of
Intake to complete the following:
Y /(N/
Is uson LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
/N
ill there be food preparation?
If so, give applicant a Health Department form.
Zoning review can not begin until we,teceive approval from Health
Dept. FAX DATE
FnAA�
Circle the one that applies
Is parcel on private well ublie water
If private well, provide Hea De ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the f7tli3 lies
Is parcel ortseptic gr public sewer?
-,�
Y N
Wi u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
Will e be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followin
Reviewer to complete the ollowing:
Square footage of Use.
13ermined as: vA 6
Under Section: f m;(�
Supplementary regulations section:
Parking formula:
!J� SIB iU.n
Required spaces: rl
olations:
Y/N
so, List:
LTC .(
Pro
Yk'/
If so; List.
Vari,,44,,ce:
lf d�-
Ifs --List:
SP'
I %
IfS4, st:
Clearances: [)
ICI 7 ��KM
Ca
SDP's
Revised 11/1/2015 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, ' C L
[County application narneand number]
was provided to ofG the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
mann r identified below: , — cc,). �I An
Hand delivering a copy of the application to CalScho&
[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 2 �6 I —1
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].
Yrmt�Appplicant Name
V/)J / / -7
Date
fceD "i2�C K
r-
LD CIO DO
�7
Cimp �„�•
COMMONWEALTH OF VIRGINIA
VIRGINIA DEPARTMENT OF HEALTH
In accordance with the regulations of the Board of Health of the
Commonwealth of Virginia this certifies that
Littlejohn's Crozet, LLC
is hereby granted a permit/license by the Albemarle County Health Department to operate a
Mobile Food Unit
Trading as:
LITTLEJOHN'S CROZET
Located at:
6135 Rockfish Gap Turnpike
Crozet, VA, 22932
Mailing Address:
1118 Crozet Avenue,
Crozet, VA, 22932
Conditions of Permit (if applicable);
Conditions Outlined in Letter Dated October 17, 2016 Must Be Followed.
Date of Expiration
October 31, 2017
Eric S. Myers, REHS
Environmental Health Supervisor
THIS PERMIT IS NOT TRANSFERABLE FROM ONE INDIVIDUAL OR LOCATION TO ANOTHER
New owners are required to make written application for a permit.
Please Direct Questions or Concerns to the
Albemarle County Health Department
Environmental Health Services
PO BOX 7546
Charlottesville VA 22906
(434) 972-6219