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Home My WebLink AboutCLE201700281 Application 2018-01-12R{T ` n n or E nin 6 nce Application fy� .: CLE # J PLEASE REVIENV ALL 3 SHEETS OFFICE USE ONLY AVI��iL Y47I.�9ADate: 17 1$ • J7 eceipt # ;('Xd it ald Staff: J-NOZA9.4- PARCp L INFORM AT Existing Zoning DD a �3 n gq VeS( Q,nf_& ` Tax Ma and Parcel: VI U � V'� Parcel Owner:- 11�►ls�- Parcel Address: ,t) (hdAtVLJ city C1�GCiO S i��=-State 6(f�J)(l�\r^ Zip`412.901 (include suite or floor) PRIMARY CONTACT Cr KGB Who should we call/write concerning this project? fCy `y -' L4_-51 — 1& 6 Address: 9 4l 44. l? oe ckyo t City �1^n'la} t jam'(\ ` State �'%/i i ��o c� Zip 2nO l Office Phone: ti 7 Cell # �3y'�bl� 3F Fax #1 JA -9-10 -Zt�I &mail ✓taf 9i-{ �u> Pf0=4lA A ,,Ca U9 APPLICANT INFORMATION Check any that apply: Changeofownership Change of use Change of name New business P�5! i2' 6ec k L1,L G a 6r., ham{ 5 Business Name/Type: S 1 R c P Previous Business on this site NO Nt Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of vehicles, and any additional information that you can provide: I :tr *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. 1 hereby certify that 1 own or have the owner's,pennission to use the space indicated on this application. I also certify that the information provided is true and accurate o the best of ny wle ge. 1 have read the conditions of approval, and I understand them,,a(nd,that 1 will abide by them. Signature t-� Printed C�v "(L I � W� APPOVAL INFORMATION Approved as proposed [ ] Approved with conditions [ ] Denied [ ] Backflow prevention device and/or cuiTent test data needed for this site. Contact ACSA, 977-451 1, x 117. [ ] 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 ate. Notes: It YUdJ Building Official Date ot Zoning Official Date 'hot Other Official Date County of Albemarle Department of Community Development 401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-1,832 Fax: (434) 972-4126 Fe- iced l 1 '02 2015 PaVe 2 of Intake to complete the following: Y /QN Is usLI;HI or PD1P zoning? If so, give applicant a Certified Engineer's Report (CER) packet. Y / N 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 public water? If private well; provide Health Department fonn. Zoning review can not begin until we receive approval from Health Dept. FAX DATE Circle the one that applies Is parcel on septic or public sewer? Y Wil u 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 COM Violations: Y/N If so; List: Variance Y / N If so; List: Clearances: etc the follOIN4112: Reviewer to complete the following: Square footage of Use: OLV Q/ N Permitted as: mo -� Under Section: ' (� Supplementary regulations section: I Parking formula: St- Required spaces: Y/N Items to be verified in the field: (t(al1u - ex- Prof Y/N If s _ist: SP's: Y/N If so. List: SDP's - Reviscd 1121'2M) ' Pare 3 of? l 1 0►PDiG e -D2 CO- J M 0 t sbir3 --> I I S r ' -'t 1 5 i J C , 1-,x E7, C1-7 C0aF/ Virginia Department of Social Services REQUEST FOR BUILDING EVALUATION OR INSPECTION SECTION I (To be completed by applicant) �f,?V-q 70, -- 110V (ApOicant's Name) T (Telephone number) (Applicant's Address) I hereby request the building located at the following address be evaluated by the Building Official (and inspected if determined necessary by the Building Official) for compliance with the Virginia Uniform Statewide Building Code (VUSBC): r. 110 a- GP;'/ le- 1 '2- Building Address (provide complete address) Building name or number NOTE: If multiple buildings are used, please enter information for each building on a separate form. I plan to use the building to operate the following: Family Day Home* EJ Licensed Child Day Center* arc-hildren's Residential Facility* Religious Exempt Child Day Center* ❑ Certified Preschool or Nursery School Adult Day Care Centert El Assisted Living Facilityt *For children's programs, specify the total number of children to be served: and the number of children served who will be 2 1,1" years of age or less: tForadult prograrns, specify the total number of adults to be served: vj�. and the maximum -number of adults who at any given time will not be capable of'self-preservation (non -ambulatory): AZ - I will bear any associated costs incurred. )jjte: Signature of Applicant: The VUSBC 6roup Classification required for the use indicated above: Maximum Occupancy Load (including staff): __ ( __ non -ambulatory) The building identified above has been evaluated based on the inforniation provided and inspected, if necessary, and is determined to be property classified under the VUSBC for the indicated use and number of occupants. (7on-irrients (if any): b W EL L AO,.-, /,40 d� A�. Date: 11141S Suture ot'Building Official: Printid Warne of Building Official 032-05-0341-04-eng (10/11) Telephone Number VIRGINIA DEPARTMENT OF SOCIAL SERVICES ACKNOWLEDGMENT OF INSPECTION Name of Facility: Start Time: E��,�. ( End Time: ! . ❑ Inspection Attempted Time: ❑ Inspection findings were reviewed on this date. t, 1, DIVISION OF LICENSING Date: Type of Inspection: ❑ New/Initial ❑Renewal ❑Monitoring []Complaint ❑ Training/Consultation Wther A review of inspection findings by the Licensing Inspector has identified anticipated violations in at least the following areas of the licensing standards. (NOTE: Further review of the inspection findings prior to the completion of the inspection documentation may result in the citation of additional violations) .y Comments: If a monitoring inspection was conducted, this document must be posted until receipt of the complete inspection documentation. It is a mutual agreement that the inspection documentation will be sent by the method checked below: -Email ❑ Fax ❑ Mail: (Please specify) Division of Licensing Representative/Dater ( Facility Representative/Date DOLP maintains original Copy to Facility Representative 032-05-0981-02-eng (10/16) 1 Fire Prevention Application ALBEMARLE COUNTY www_ACtireRescue_org Reinspection -1 Assigned To AYERS, Joey on 1/12/2018 Fee $0.00 Start Date: 1/12/2018 3:35:45PM Business Name: The Stars Program (Resident Group Home) Address: 110 Middlesex DR City/State/Zip: Charlottesville, VA 22901 Violations Date Found 2009 VFC CH 06 Unapproved Conditions 1/11/2018 Standard: Long Desc: Unapproved conditions. Relnspection Date: Finish Date: 1/12/2018 3:37:35PM Occupancy ID: 22592 Station No.: Seminole Trail Phone: Date Cleared 1/12/2018 Open junction boxes and open -wiring splices shall be prohibited. Approved covers shall be provided for all switch and electrical outlet boxes. Comments: All open junction boxes shall be covered. STATEMENT OF RESPONSIBILITY I hereby acknowledge that the information contained herein, and declare that it be true and correct to the best of my knowledge and belief. Further, I am the ownerloperator, or a duly authorized agent, acting on behalf of the owner, for all activities at the above mentioned property or location. As such, I hereby agree to comply fully with all the requirements in the Albemarle County Fire Prevention Code governing the operation I wish to conduct. If there has been any false statement or misrepresentation as to the material fact in this application, data, or plans on which the permit or approval was based, the Fire Marshall may revoke this permit. Page:1