HomeMy WebLinkAboutCLE201200232 Legacy Document 2012-12-13(�U ffVIAa,
Application for Zoning Clearance
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CLE # Z ` 2--3Z
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY i n 2� l Z
Check# 1262�O Date:
Receipt # Q3 Staff: �j
PARCEL INFORMATI O
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Tax Map and Parcel: _ - _ I Existing Zoning
Parcel Owner:5OAMd.-4PEs:. % KC42 Ckf&-t-
Parcel Address: 32o L-,ue- CityOA/ddhesville State V# Zip 92l/
(include s ite or floor) Sv'�fc to U
PRIMARY CONTACT
Who should call /write concerning this project?
/we
q0V l f Ceyja 3?1G'% 2�h��%
Address : l�tisl,l) city State 1 Zip
Office Phone: (� _7) 7 �� �7%�� Cell # 61b44--&F1( Fax #,2)6 7 ����1� E -mail fi W 6,7191 o�&ZO Qaa
APPLICANT INFORMATION
Check any that apply: Change* of ownership Change of use _Change D� New business
/o�f_name
Business Name /Type:
%
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: S'2e, A_ f j-A G h e 4. 6-'t ,-_
*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 accyrate to C e best f -myy1Y oy 11edd&e.,I have read the conditions of approval, and I understand them, and that I will abide by them.
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Signatur (i/ ./V Printed
APP AL IN-FORMATION
[V 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 c Date ((I (S—
Zoning Official - YU11 Date
- I �&dg- Z 4
r
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 7/1/2011 Page 2 of 3
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0-10;179
Intake to complete the following:
Y / 0
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y N
W il 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 ublic water
If private well, provide Hea ' ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that app ' s
Is parcel on septic or ublic sewer
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: 1663..
Y N
ermitted as:*' 1(�Q
Under Section: P
Supplementary regulations section:
Parking formula: I I R
Required spaces: 5'
Y/N
Items to be verified in the field:
Inspector : / Date:
Notes:
Violaons:
Y /(N)
If so, st:
Proffers:
Y/
If so, ist:
Vari ce:
Y/N &
If so, Dist:
SP's:
Y/N
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
Quest
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SVVDiagnostics
Sao w LN d "M�- R( V*L LAWr --
To Whom It May Concern:
It is the intent of this letter to advise the municipality as to the type of business we will be
conducting at the above - mentioned address.
Quest Diagnostics will be utilizing the facility as a Patient Service Center with ancillary
office use. Our phlebotomists will collect patient's specimens and forward to our
laboratory in Baltimore, MD & Chantilly, VA for testing. The Patient Service Center
does no testing — it is strictly a draw site.
Our hours of operation will be approximately 7:00 am to3:30 pm Monday thru Friday.
We will employ one full time employee. We do not store any drugs at the site and will
not be parking any vehicles onsite overnight. Our anticipated number of patients visiting
the site on a daily basis will be approximately 25 -30.
If you have any specific questions, please feel free to contact me at 215- 444 -8253.
Thank you for your assistance.
Sincerely,
Ron R,ussak
Ron Russak
Director of Patient Services
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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, 0 Cle&,1.4 AJ,-
n [County application name and number]
was provided to I `Z a lob a -A 2 Spo l �,k�1� e owner of record of Tax Map
[name(s) of the record owners df the parcel]
and Parcel Number3W W ,tjkp, 2i LjN by delivering a copy of the application in the
manner identified below:
Hand delivering 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
-f.-Mailing a copy of the application to ' (a C-44-a-1 Cfi2 -fe l2
[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 to the following address:
Date
[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].
Print Applicant Name
/� //� �Z
Date