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HomeMy WebLinkAboutCLE201700125 Application 2017-06-05�5�o Se.�n���l� `�ra:l Application for Zoning Clearance /i `' CLE # 00 /1 N A 9'6N4' PLEASE REVIENN"ALL 3 S"EFTS Check Date: - P7 i Receipt # 1 Cf Staff: PARCEL INFORMA13?j,, Tax Map and Parcel: ) _ ()I _ 00 ()1 _50 Existing Zoning Parcel Owner:— Fef'IiO46 �qA* TAV"t0M4A Parcel Address: —I" 2 A '3 We �" ""ACity Alk AL- State (inclubi suite or floor) PRIMARY CONTACT Who should we call/write concerning this project? Address : -2 0 � Set M &V eL, 0tv LA rl-/a�/11.- State zip Cell t# A iiofrice Phone; tffi -n APPLICANT INFORMATION Check any that apply: Change of ownership fitanp Change of name New business e of use Business NamefVype: Previous Business on this site Describe the proposed business including use, number of employeq, not lber of shifts, avail bke parking sliaces, umber of vehicles, d any inforn - t vide-Dal-4 1111v I" i ion tha c n pro T'* clearancev.'ill only he valid on the parcel lor which it is approved. If you Or-utre. iotensi6 or move the use to a new location, a new Zoning Clearance will be required. I hereby certify that I ov%n or have Ow o%viler's perinks-- sion 14) u- the Npac': todicatcd (,it this application. I Aso certify that the irsibmuti6n It"wided is true and accurate to the -s I - ly knov%lcdge. I have read the conditions ofappro%al. and I understand them, and that I swill ahide by them. Signature Printed — APPROVAL INFOR-MATION Approved as proposed Approved with conditions Denied Backilow prevention device and or current test data needed for this site,. Contact.A('SA. 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. [ j This site complies with the site plan as of this date. Notes: Building Official Date Zoning Official Date Other Official Date County of Albemarle Department of tuortitnunity Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fix: (434) 972-4126 Revised 7/1 /2011 Page 2 of 3 IV\ Intake to complete the following: Y/6 Is use in LI, HI or PD1P zoning? Engineer's Report (CER) packet. If so, give applicant a Certified Y /O 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 Circle the one that applies Is parcel on private well or p jc ter? If private well, provide Health partment form. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that applies Is parcel on septic o u lie s er? Y/N Will you be putting up a new sign of any kind? If so, obtain proper Sign permit. Permit # Y/N Will there be any new construction or renovations? If so, obtain the proper Permit. Permit # Zoning to complete the followinp,: Reviewer to complete the following: Square footage of Use: lio 6 b 6 / N Permitted as:�„�.�/9� Under Section: Q,Q;,,.i Supplementary regulations section: Parking formula: Required spaces: Y i N Items to be verified in the field: Inspector : Date: !Votes: Violat'ons: Y /& If so, List: Prof 'e: Y / If so, List: Variance: Cj)/N If so, List: SP's: S)/N If so, List: �- 13 g - 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: 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 Ti ^k tto tl\ [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: no [address; written notice mailed to the owner at the last k".4, addr ss Athe owner as shown on the current real estate tax assessment books or current real estate tax assessment records satisfies this requirement]. 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THIS AFFORDED BY THE POLICIES ING INSURER(S), AUTHORIZED ATION IS WAIVED, subject to .ate does not confer rights to the :RAGE NAIC # 74 CO 10851 NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR LTR TYPE OF INSURANCE ADDLSUBR INSR WVD POLICY NUMBER POLICY F-FF I IMM/DD1YYYY1MM/DD/YYYY POLICY EXP LIMITS B GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR S18ML00041-161 12/31/2016 12/31/2017 EACH OCCURRENCE $1,000,000 DAMAGE TRENTED PREMISES Ea occurrence $500,000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO X LOC PRODUCTS - COMP/OP AGG $2,000,000 $ AUTOMOBILE LIABILITY(Ea ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS AUTOS accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE EXC6018961 12/31/2016 12/31/2017 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DED I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- RY IMIT 1 ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement. rCDTICIr`ATP LJnl r15=D CONCFI I ATInN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserves. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD