HomeMy WebLinkAboutCLE201300272 Legacy Document 2013-11-22Application for Zoning Clearance
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # Date: / '7
Receipt # Cl �je lr Staff:
PARCEL INFORMATION
Tax Map and Parcel: 07800- 00- 00 -055AO Existing Zoning
Parcel Owner: Medical Enterprises Group Associates, LLC
Parcel Address: 1490 Pantops Mountain PI. #200 City Charlottesville State Virginia Zip 22911
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? Hakan Dagli
Address: same as above City State Zip
Office Phone: (434) 8794440 Cell # 434 953 -9486 Fax # 434 979 -4441 E -mail hadagli @sentara.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use X Change of name New business
}a.- Zc•�h� CO.rP
Business Name /Type: Pantops Family Medicine, A Division of Anchor.We,�ea~a, PLC (Medical Practice - Family Medicine
Previous Business on this site Pantops Family Medicine, PLC
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: continuation of family Medicine clinic, 10 employees, M -Fri,
8am -5pm, No service or functional changes are occuring- only name anci en i y type are c angmg.
*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 to owner's permission to use to space indicated on this application. I also certify that to information provided
is true and accurate to thpT),qst of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature / Cam_ Printed HAKAN A DAGLI
AP AL INFORMATION
[� Approved as proposed [ ] Approved with conditions [ ] Denied
[ ] Bac ow prevention device and /or current test data needed for this site. Contact ACSA, 977 -4511, x117.
[ o 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 3
Zoning Official Date 1
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
Intake to complete the following:
Y
Is us m LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y / 9th' Will 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 o public water?
If private well, provide He ent form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli , s
Is parcel on septic or p lic sewer?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Wi��fere 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: �4 D LI
DrmYI N -� itted as: q � �
Under Section: 1 1 ' a 01
Supplementary regulations section:
Parking formula:
Required spaces:
6
Y/N
Items to be verified in the field:
Vi a 'ons:
Y/N
Ifs ist:
offers:
LY/N
so, List:
iance:
Y/N
o, List: �(�(�
's:
Y N
so, List:
Clearances:
SDP's l ��
Revised 7/1/2011 Page 3 of 3
o 1
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 Clearance - Albemarle Co.
[County application name and number]
was provided to Medical Enterprises Group Associates, LLC the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 07800- 00- 00 -055AO by delivering a copy of the application in the
manner identified below:
Warren Quillian, Manager
X Hand delivering a copy of the application to Medical Enterprises Group Associates, LLC
[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 November 1, 2013
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 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].
SignaUi 6 of Applicant
Hakan A. Dagli
Print Applicant Name
November 1, 2013
Date
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