HomeMy WebLinkAboutCLE200900168 Legacy Document 2012-10-111
Application for Zoning Clearance
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CLE # C '" I C¢ S
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Zoning Clearance = $35
OFFICE USE ON LY
Check # � G' � LO c� Date:
PLEASE REVIEW ALL 3 SHEETS
Receipt # —7(o,U 5g! Staff: f✓
PARCEL INFORMATION
Tax Map Parcel: �tJ Existing Zoning
and U�
Parcel Owner: March Mountain Properties LLC
1005 Hea.thercroft Circle
Parcel Address: Suite 400 City Crozet State yA Zip 22952
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Jim Wilson C/O Augusta Health
Address: PO Box 1000 City Fishersville State VA Zip 22939
Office Phone: 5( 401932 -4801 Cell # (540) 649- 1524Fax # (540) 932 -5842 E- mail'ijwi l sonlaaljg>>stahP -al th_ccr
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: Augusta Health Int6rnal Medicine
Previous Business on this site N/A
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: Dr. Office, 5 Employees, lst Shift .
*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.
tgnature Printed
APP OVAL INFORMATION
[ Approved as proposed [ J Approved with conditions [ ] Denied
[ ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977 -4511, xl 19.
[ ] 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
Zoning Official Date
11r
Other Official Date
n
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296 -5832 Fax: (434) 9724126
Revised 04/28/08 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 /
Will 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 ublic water?
If private well, provide Heat epartment 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 public sewer?
Yj/ 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,; he proper Permit.
Permit # 6.•()Q C(— CJ (Q j-
Zoning to complete the followinIZ:
Reviewer to complete the following:
Square footage of Use: /7SO
/N J
ermi tted as: �!� C is ( �'F! C e-
Under Section: CC>CLe. O�CJ ✓�r 102 YI`P t
Supplementary regulation tecction:
Parking formula: �1-
1
Required spaces: n
Y/N I
Items to be verified in the field:
Inspector: Date:
Notes:
Viola ' ns:
If st:
Y Fli
P ffers:
Y/ N
, List:
Tare:
t:
SP's:
'' /N
If , List:
Clearances:
SDP's
Revised 04/28/08 Page 3 of 3