HomeMy WebLinkAboutCLE202000091 Application Zoning Clearance 2020-06-10Application for Zoning Clearance
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Check # Date:
Receipt # Staff:
PARCEL INFORMATION
Tax Map and Parcel: Tax Map 78 Parcel 11A (Portion of) Existing Zoning HC
Parcel Owner: ALBEMARLE LAND, INC.
Parcel Address:4100 OLYMPIHIA DRIVE City CHARLOTTESVILLE State VIRGINIA Zip
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? JODY HALLORAN
Address: 595 MARTHA JEFFERSON DRIVE City CHARLOTTESVILLE State VA. Zip 22911
Office Phone: (_434) 654-8520 Cell # 434-249-4588 Fax # 434-654-8521 E-mail jody.halloran@rmscva.com
APPLICANT INFORMATION
Check any that apply: X Change of ownership Change of use Change of name New business
Business Name/Type: REPRODUCTIVE MEDICINE & SURGERY CENTER OF VIRGINIA
Previous Business on this site NONE
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:
Lei/ nffiro 1\/ corlofinn fnr nrnrorluroc 1A omnlnvooe 1 hif4 RA n rlrinn ennroc Thoro nra nn rmmnnv vohirloc
*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 Printed Jody Halloran
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 U
Zoning Official - "' Date
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 11/02/2015 Page 2 of 3
Intake to complete the following:
Is /
Is u n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / Wil eI�h re 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 pu is :wa
t
If private well, provide Health ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies -
Is parcel on septic or blic se er?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Reviewer to complete the following:
Square footage of Use: Zino
Y/N
ermitted as: i
Under Section: Z�c 2 f Zs,
Supplementary regulations section:
Parking formula: �� 76's
Required spaces: S L (- (5 14 3) t 5-bt)2ZY6 —
Y /
Ite o be verified in the field:
Inspector:
Y / N Notes:
Will there be any new construction or renovations?
If so, obtai the proper Permit. l
Permit # Zola' Did jl -�C,/ �2o2,v 1 0.34C
Zoning to complete the following:
Date:
Violations:
Y / �
If so � ( J C,/f� ( 0 2-T ti — <5 3 ')
Prof rs:
Y / jN )
If so,%,. sit:
Variance:
Y/N
If so, List:
SP's:
y/�
If so, st:
Clearances:
C2 c9✓1 L
SDP's
2-6G/�1'S��
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, ZONING CLEARANCE
[County application name and number]
was provided to ALBEMARLE LAND, INC.
[name(s) of the record owners of the parcel]
the owner of record of Tax Map
and Parcel Number TM 78 PARCEL 11 A (PORTION OF) by delivering a copy of the application in the
manner identified below:
0 Hand delivering a copy of the application to Albemarle Land Inc.
[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 6/20//2020
Date
0 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].
Signature of Applicant
Print Applicant Name
Date
(A�
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OLYMPIA DRIVE
CHARLOTTESVILLE, VA 22911
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TITLE
OVERALL LEVEL 02
FLOOR PLAN AND
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SHEET NUMBER
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