Loading...
HomeMy WebLinkAboutCLE201700102 Application 2017-05-23Application for Zonin Clearance OFFICE USE ONLY ' t PLEASE REVIEW ALL 3 SHEETS Check# Gate: Receipt # aff: PARCEL INFORMATION /� Tax Map and Parcel: -� - 1 — a(� 100 Existing zonin Parcel Owner: S v f k l� � � l/u �` �t f %(� S_G 4 coo / Parcel Address: 2401 Pa wt< ll 6t_ek Ur City State �� _ Zip 72 - (include suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? / Address: 312 L %/Ya o acc n �/�� ✓(' City C�,q✓��o (SVi��� State V ✓t Zip 2290 Office Phone: Cell # Fax # E-mail ��au ��c/Z a%bEr�✓ �N. c APPLICANT INFORMATION Check any that apply: Cbange of ownership _ Change of use Change of name New business Business Name/Type: �- Py Aim v c. l T "Ae C�J('4CC- lay 5/<-- R ('.✓J T Previous Business on this site uescrrpe the proposes business Including use, number of employees, number of shifts, available parking spaces, number of vehicles, and any additional information that you can provide: Y *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 Zaning Clearance will be required. I hereby certify that I own or have the wner's permission to use the space Indicated on this application. I also certify that the information provided is true and aceuta owledge. I have read the conditions of approval, a`nnd,II understand them, and th-/at I will abide by them. est Signature 11�dx� Printed / _r `t i¢ 4C,t') ,s. �/APt5 APPROVAL INFORMATION Approved as proposed [ ] Approved with conditions [ ] Denied Baekflow 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 Zoning Official Date Date`1�,��7 i Other Official Date County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126 Revised 11/1/20I5 Page 2 of 3 0 mapmyrun Cr)Q' 152v Independence Day 5K Kiwanis Distance:3.1 mi Elevation: 188.2 ft (Max: 511.29 ft) a y elf 1521 �Or ake giftbe.r{lef.., -ram 1523 1517r4t 15Z5 �tyye� 15z: .ram 1525 ■o■ - :_ ELEVATION (ft) 0. 9 Baker -Butler Elementary School rU f If l I 0ong�os��� `C�zo t'Aap data ©2016 Gooyle * 0 1 2 3 Miles Copyright (cti 2016 MapfalyFdriess Inc. o=- _ Kiwanis I at S I I Ld9l& S 4chI• �lk*�- � Z 1,k 341"Annual ***lk� -jk INDEPENDENCE DAY 5K RUN WHEN: Tuesday, July 4, 2017, at 7:30 a.m. WHERE: Forest Lakes Subdivision: Sutherland Middle School Sponsored by BETTER and Hosted by Kiwanis Club of Charlottesville and Charlottesville Track Club LIVING To Benefit Camp Holiday Trails Over $130,000 has been donated to this charity over the years! ------------------ REGISTRATIONINFORMATION------------------ Fee: $25 CTC members, $26 non-CTC members, $20 Students, $30 all race day entries Please make checks payable to: Kiwanis Club of Charlottesville 4 Ways to Register: By Mail, prior to June 30: Kiwanis Club, 925 Dorchester Place #303, Charlottesville, VA 22911 Hand -Deliver, by 5 p.m. on July 2: Ragged Mountain Running Shop Online: http://charlottesvilletrackclub.org In -Person on Race Day, 6:30 a.m.: Sutherland Middle School Cafeteria, 2801 Powell Creek Drive Award categories for all age groups, including the youngsters (10 & younger)! "My 4th of July experience has been enriched over the years, thanks to this wonderful community event." — Mark Lorenzoni For more information, email: indegendence5k@gmail.com or visit our Facebook Page: Kiwanis Independence Day 5K Last Name: First Name: Address: City: State: Zip: Daytime Phone: Email (optional): Age on Race Day: Sex: M F T-Shirt Size: Child S M L XL 2XL CTC Member: Y N LIABILITY WAIVER MUST BE SIGNED I know that running a road race is a potentially hazardous activity. I should not enter and run unless I am medically able and properly trained. I agree to abide by all decisions of the race officials relative to my ability to complete the run safely. I assume all risks associated with running in this event, including, but not limited to, falls, contact with other participants, the effects of weather, including high heat and humidity, traffic and the conditions of the road, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I, for myself and anyone entitled to act on my behalf, waive and release the Kiwanis Club of Charlottesville, the Charlottesville Track Club, Forest Lakes Community Association, the County of Albemarle, all beneficiaries, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in this event. Furthermore, I agree to be bound by the rules established with respect to this event. In consideration of the safety of all participants, I understand that absolutely no baby joggers, baby strollers, headphones, animals on leash, skateboard, skates, roller blades or bicycles are allowed on the course. In addition, I understand that if the race is canceled by circumstances beyond the control of the organizers, my entry fee will not be refunded. SIGNATURE (Parent or Guardian, if under 18): Date: Commonwealth of Virginia Department of Transportation 3/2010 LUP-A LAND USE PERTMT Application APPLICATION is hereby made for permit as shown on Ilte accompanyhls plan or sketch and as described below. Said activily(s) will be done tinder and in accordanceMili (tic roles and regulations ofttto Coinmomycaldt Tmiispotlation Board ofViigioia, in so far as said ndcs are applicable thereto and any agreemcni between tlreliarties herein beforercrerredlo. Where applicable agreententsmay beahRoliedand rnadoapart oriltopenititnsscriblyincIidingany cost respousibililiescovering %vorkunderpermit.Applicantagrees10 mninlain work in a manner as approved upon its completion. Applicant also h'oicby ogrees, and is boned and held responsibio to utc owner for aoy mid all,damages to any other iustallatioits already in place as a residt ofwork covered by resultingpennit. Applicants,lo whore permils arc issued shall al all times indenatiry and save hannless llie. Gotrunomycgllh Transpudation Board members ofthe Board, ilie Comnionweattli arid all Comntomwcalth employees, agenfs, and offices, froir responsibility, damage, or liabilityarising Snru f)re exercise pf Uia privileges granted in suchlionnit 10the extent alioived by low. In cousideral6a. of Vic Jisoante of a pen -tit the applicant agrees to waive for itself, successors in intoresf or assigns any entitlements it tnay otlieny]se have orligve hereafter under the Uniform RelocAtton and Assistant Act of] 972 is amended in'evehl the Deparbnein or its successor, eltooses:"lo exercise its ackboMedged right to deniand or cause the teinoval ofany croll fixhires, personality ofivhaleverkiiid or descriplion Ibatmay Iicreaticrbc.located, slrotdd'Uus applicalion ate approved. TYPE OR PRINT CLEARLY Driver's lice]ise or Tax ID number (� l'ZC b� 7f ContaatNamerl�`�t�S OwnerNan]e Lt,,Invit's CfeILy'�C�rct�`lrf%�-w- r'. E-mallA.ddress J�i�J=y�7aac5!i2 1!3GPVQt,/-C'Ca^-9 Address %'L Gil p�� �c_C-ctvt �.^r`yL� Phoh Number (f� )�___7 -� ��1' City (ihGl1_1011 _VI%V_State Zip Code �2•%U1 Emergency Number (�� 7�) PW - i Itax Number XZ2 - Driver's license or Tax ID number Contact Name AgontName :F; mail Address Address Phone Number ( ) City State Zip Code ) mcrgeney Number I ax Nuinb.er ( ) Permit Term Requested _4"r,-' aelosed $ Checic Nltmber Coupon Number(s) Money Order Otlrer• Estimated cost of -work to be performed on VDOTAglit of Way.$ Surety Information: Sin•ety Company Naine The Surety posted by Owner ( ) or Agent Amount of Surety $ Obligation.Amount $. Check # Bond # ILC # Surety Refunds paid to Owi er ( ) or Agent ( ) [ i Corporate Sigety [ 1 Resolution I .J Ordinance [ ] Waived ADolka"t-63 T4,60 ¢d_&tif 4oip•t'ello15�111k reglrlFCnlQnt,t.tll aC(�O anCe 9a deTCd I11.COd i[�,tI�A SBCtlrn23-Y�'1-MA (]) The utriittycompany,liasregisteir,ti",a �eratursvillrAieappropl7atenptMvptiot�center. r2Y Ailar<hed,is a nolaYrzelfaFGdavii, statatgtltal the utility owder has gotiGed taro aololnercial-atd re7s061ial developer.; owncrafcoainrerctal of mtikt#nmiiy reai esmle, er I6eal'�avci n e it tntilie"s tir+ilh"a properiy 4htefes(,in any parcc)`ot'Ja'da ltiaatd at teat !'o::tt�e"{trap7iiy.av�r wliich•Ihe;tait'd use is being requested; that applicationfor the•permil has beea made. Request Permission: To perform the following activity(s) i i � • Location: Tax Map Number. Geogi apluaally na Ct?iinty of %k Bettiveeii Rout St. Namme V t.IJ Il And Route St. Naive A,:AWvW j J IV APPLICAIILE, l Ar-REE TO'PAV TI3R Ft'7L G'ONJU1�CTlON 1►rI7A1HT$ ; Signature of applicant Signature of agelit as 1 Applica]it Job No, , L'ri'lcif' e' On Highway Route and for Name iE't7 wGy r:lc` V i �Gt Laiifude Longittiae Latitude Longitu .SAl' AR,X_AND-EiNT.JEN$Es, OF.. A,$,TAY.S ASSIGNED INS iSY• C[fU10,11 �G�1'SyABLEDIUMSER. Title Date Title Date per attached plans. I le R Ir4 j All applicable items oil this form intist bo co npleted to avoid delay'inproce5sing the issuance ofa VDOT-Land_ US Permit. Pfepaymeni Required - matt VDOT USE ONLit ;Remittance payable to. Vitginia Department of Tianspottationr _ ._.. Receipt is] iereby acknowledged for: QBT In The Amount of $ QK No. COUPON No. M. O, foi' I'erlrii t F10 :$ Cash Surety $ o. Authorized VDOT Signature; Date i _ Cominon-wealth of Virginia LUP--SP Department of LAND USE' PERMIT 05/2009 0 Transportation Special Provisions NOTICE OF PERMITTEE LIABILITY Permittee Agreement for Land Use Permit the undersigned Permittee/Agent, acknowledge that 1 have read and T rim fully cognizant of all of the following requirements for permit issuance. Permittep/Agent Dame Peimitfee/Agent C°•vc..J '5 • /%taL Any of the following provisions, which can apply, shall apply: Date 4� / / % / %% Permittee acceptance and use of a Virginia Depa.! tnrertt of Ti nfrsportation (VDOT) Land Use Permit is prima• facie evidence that the permittee has read and is fully cognizant of.all required permit provisions, applicable traffic control plans aad associated construction standards to beeinployed. ALL applicants to whompermits are issued shall at all times indemnify and save.haiinless the Commonwealth Transportation Bom d, in inbers of the Board, the Colnuuaruvealth, and all Comoro wealth employees, agents, and officers, from responsibility,_ damage, or liability arising from the exercise of the privileges granted 'in such permit to the extent allowed by law. 2. The pemrittee agrees.to secure and carry insurance against liability for personal injury and property damage that may arise from the work performed .tuiderpermit and/or from the operation of permitted activity -up to one Brillion dollars ($ 1,000,000) each occurrence to protect the Board members and the Department's agents oi' employees; seventy-five thousand dollars ($75,000) each occurrence to protect the Board, the Departrrc.eut,_ or the Comptompealth in event of suit. 3. The perm ttee assumes full responsibility for any and all (downstream flooding, erosion, siltation, etc.) damages that may occur as a result_of the work performed under this permit. FW thermore, the Department will in no way be responsible for any damage to the facility being placed as a result of fixture maintenance or construction activities, performed by the Department. 4. The pennittee agrees to.inove, remove, alter, or change any installation that interferes with the ultimate construction of the highway in alignment or grade at NO cost to the Deportment unless otherwise stipulated and. agreed to. by the Deparithe.w. 5. The permittee shall immediately correct any situation that may arise as a result of these activities that the Residency Administrator or his/her representative deeins hazardous fo. the traveling public. 6. Any and all highway signs; right -of --way markers, etc., disturbed as a result of work performed under this permit shall be accurately reset by the permitted immediately following .the work in the vicinity of the disturbed facility. The services of a certified land surveyor with experience in route surveying may be required.