HomeMy WebLinkAboutCLE201800253 Application 2019-01-16Application for Z ning Clearance
CLE #
. � w
OFFICE US O Y
PLEASE REVIEW ALL 3 SHEETS Check # Date: I
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: 061WO-0300.02600 Existing Zoning Ct
Parcel Owner:_ OHI Asset (VA) Charlottesvllte, LLC
Parcel Address: 1150 Northwest Drive City Charlottesville State VA Zip 229111
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Clint A. Nichols
Address : 4701 Cox Road, Suite 400 City Glen Allen State VA zip 23060
Office Phone: i 8O) 967.9604 Cell # Fax # 804-987-8868 E-mail cnichols®hancockdoniel.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: Nursing Home
Previous Business on this site Nursing Home
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: Existing business - change of ownership
'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 1 own or have the owners permission to use the space indicated on this application, t also certify that the information provided
is true and accurate tZn best of my knowledge. I ave read the conditions ofapprovel, and 1 understand them, and that I will abide by them.
Signature Printed Clint A. Nichols, Counsel
APPROVAL INFORMATION
[ ] Approved as proposed [ ] Approved with conditions [ J Denied
( ] Backflow prevention device and/or current test data needed for this site, Contact ACSA, 977-45 1I, x117.
[ I 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 Z/ /
Zoning Official Date I (a 41'(
Other Official , Date 01 >f��
unty of Ibemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fax: (434) 972-4126
Revised 11/02/2015 Page 2 of
Intake to complete the following:
Y /QN11
Is usI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
ill 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 �mernt
If private well, provide Healt orm.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or p is sewe ?
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: 1 7, 0
/ N \
Permitted as: -f�.j t.ry b11A Yu.I`J t l
Under Section: SP R D
Supplementary rep
,dations section:
Parking formula:
Required spaces:
15H
It { N/
Ite o be verified in the field
Inspector:
Notes:
Date:
Violations:
Y/N
If so, List:
Prof
y 7
If so -, -List:
Variance:
Y/N
If so, List:
SP's:
Y/N
If so, List:
Clearances:
SDP's _ I
LPN 8
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, Albemarle Zoning Clearance
[County application name and number]
was provided to OHI Asset (VA) Charlottesville, LLC the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 061w0-0300-02600
manner identified below:
0 Hand delivering a copy of the application to
by delivering a copy of the application in the
[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 Leighton Aiken, Counsel
[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 December 14, 2018
Date
to the following address:
303 International Circle, Suite 200, Hunt Valley, MD 21030
[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].
tgnature of Applicant
Clint A. Nichols
Print Applicant Name
December 14, 2018
Date
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