HomeMy WebLinkAboutCLE201800231 Application 2018-11-20�035-1561J
Application for Zonin Clearance/'°�A`9
CLE #�,
OFFICE USE ONLY r
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PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff: L"
PARCEL INFORMATION r
061 UO-01-00-01100
Tax Map and Parcel: Existing Zoning
Parcel Owner: Adams & Garth Inc.
Parcel Address: 2119 Berkmar Drive #101 City Charlottesville State VA Zip 22901
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Melissa Wampler
Address : 625 Mount Clinton Pike, Suite A City Harrisonburg State VA Zip 22802
Office Phone: 5( 40) 434-9675 Cell # 540-578-1209 Fax # E-mail mwampler@q-staffing.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name/Type: Qualified Staffing of Virginia, LLC/staffing employment services
Previous Business on this site
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: Name change only
*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 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 to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature MdZ44a,Wax nple r Printed Melissa Wampler
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] 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 Date 11
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Sri
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
Is / u Is LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /n
Wil ere 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 w er?
If private well, provide Heal ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic or p blijse
r?
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 following:
Reviewer to complete the following:
Square footage of Use: �-b 10
Y/N
Permitted as: Q �j -k
Under Section: A' . A .'
Supplementary regulations section:
Parking formula:
yAM) oo
Required spaces: 1
Y / t
IterVto be verified in the field:
Inspector:
Notes:
Date:
Viols ,��s:
Y /(N/
If so, ist:
Pro r
Y N
If so, ist:
Var' e:
Y /
If sig, List:
SP'
Y
If so, List:
Clearances:
coos -I �.
SDP's
! G 7
acI Rao
C1 —30, ?q
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, Application for Zoning Permit
[County application name and number]
was provided to Adams & Garth Inc the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 061 UO-01-00-01100
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to Adams & Garth Inc - Tom Smith, Officer
[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 11/1/2019
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].
MeU4S-cvWa4VtPW
Signature of Applicant
Melissa Wampler
Print Applicant Name
10/30/2018
Date