HomeMy WebLinkAboutCLE201400007 Legacy Document 2014-01-14Application for Zonin Clearance
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CLE # �Z.C� -'
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONLY
Check # t0""Y Date: 1 ha
Receipt # 5l 19 Staff:
PARCEL INFORMATION
Tax Map and Parcel: 056A2- 01- 00 -020A0 Existing Zoning BDwmTw Cr=z2t Distdrt
Parcel Owner: Michael B. Alexander
Parcel Address: 1193 Crozet Avenue city Crozet state VA Zip 22932
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? Genevieve Blair, Practice Manager
Address : 900 Rio East Court, Suite A city Charlottesville state VA zip 22901
Office Phone: 4( 34) 975 -7777 Cell # 434- 960 -8989 Fax # 434 - 975 -7774 E -mail gblair 1piedmontpediatrics .NET
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name ,_New business
Business Name /Type: _Piedmont Pediatrics a Division of Anchor Healthcare, PLC
Previous Business on this site Crozet Family nental
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: Pediatric healthcare office with three employees working
park+'
Appmx
one shift. . eight Rg 6paG es .
*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 h best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Gretchen W. Brantley
APPRO INFORMATION
;4 Appr ved s proposed [ ] Approved with conditions [ ] Denied
[ ] Back 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 f r 1,4
Zoning Official i Date Z &V/2'On
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 use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/
Will 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 ublic wa r?
If private well, provide Heal artment 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 p lic 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: Z'gQC)
Uv / N �:
Permitted as: A21(4 Z pf� (e,,
Under Section: '2.() . 3 • Z - /3
Supplementary regulations section:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector : Date:
Notes:
Violati ns:
Y/V
If so, List:
Prof rs:
Y //N
If sb,, ist:
Variance:
Y/
If so, t:
SP's:
Y/ I
If so, ' t:
Clearances:
SDP's
Revised 7/1/2011 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, Application for Zoning Clearance
[County application name and number]
was provided to Michael B. Alexander the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 056A2- 01- 00 -020A0 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
xx Mailing a copy of the application to Michael B. Alexander
[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 `��� �Clj 9"12of to the following address:
Date
2109 Morris Road, Charlottesville, VA 22903 -1722
[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].
of Applicant
K Brantley
icant Name
Date
60' ■
3'
3-8" Server Closet
' -9- 3'2" 2 28.53 sqft.
5' Bathroom 2
23.35 sqft.
4' 8" Rear Entry
76 sqft.
IT Exam Room 4
Utility 2 S1" 6' 87.03 sq£t.
14.01 sgft.
6' S"
7-1" 11..
Lab z43.92 sqft. 6,
6' 3"
Exam Room 3
81 sqft.
14'4" 3'
Mad Room
109.92 sqft.
9'
72"
3'6" Nurse Station
184 sqft.
6'
Office 13,2" Exam Room 2.
y 47.88 sqft. 81 sqft.
9'
2' 4"
fi Bathroom 1
V 56 sqft.
8' Hallway
61 sqft.
Exam Room 1
87.3 sqft.
2-8"
S' 2"
Utility 1
2-8" 24.03 sqft.
Storage Closet
25.69 5-11"
5' 6"
9'
�—
9-4" QT 2' 11"
q, 6„ y.
14'2"
Lobby
255.47 sqft.
17-1"
Reception
155.88 sqft.
ITS., 12'7"
36"
30'