HomeMy WebLinkAboutCLE201400124 Legacy Document 2014-07-02ILEM
Application for Zoning Clearance
CLE #2014-124
OFFICE US LY
LP " - I
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # 10 Staff:
PARCEL INFORMATION
Tax Map and Parcel: 056A1 Part 1 Existing Zoning Corn for Business and Retailing
Parcel Owner: Blue Goose L.C.
Parcel Address: 1186 Crozet Ave, 2nd Floor City Crozet State VA Zip 22932
(include suite or floor)
PRIMARY CONTACT
Who should we call /write concerning this project? Benjamin Pumphrey
Address • 1705 Goose Creek Road City Waynesboro State VA Zip 22980
Office Phone: C---J Cell # 267- 357 -4186 Fax # E -mail ben.pumphrey@gmail.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Naine/Type: Blue Ridge Psychotherapy PLLC
Previous Business on this site Will be subletting space from Blue Ridge Massage Therapy
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: Will provide psychotherapy and psychiatric treatment in a subleased
office space; one employee (myself); 1 -5 days a week; 17 parking spaces for the entire office building
*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 t e best f my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature
Printed
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 1 t ( of
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 7/1/2011 Page 2 of 3
Intake to complete the following:
Y/O
Is use in LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y /
Wil 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 cubr=ent er?
If private well, provide Heal 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 bIic 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: 2-
-1) / N
Permitted as: b- i Q. tAfe.
Under Section: Zv 3.2-
Supplementary regulations section:
Parking formula: 3 4
G
Required spaces:
It / (1Q)
Items``io be verified in the field:
Inspector • Date:
Notes:
Violations:
Y/(9
If so, List:
Proffe :
Y/
If so, ist:
Variance:
Y/
If so, ist:
SP's•
Y
If so, List:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
Closet
Blue Goose Building - 1186 Crozet Ave, Crozet VA 22932
Southwest corner office of second floor
Approximately 277 sq ft
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,
[County application name and number]
�,�GelyC
was provided to the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number 056k 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
Mailing a copy of the application to�lG�c
[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 %' to the following address:
Date
C� , - - Nun f G- �-('"At UA n e-%9 a�
[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 i
Rt� I 4 wi tA--
Print Applicant Ane
6 )- -? M-- I --I
Date