HomeMy WebLinkAboutCLE201500061 Application 2015-04-20Application for Zoning Clearance
. A L�
CLE #
...
PLEASE REVIEW ALL 3 SHEETS
OFFICE US ON
Check #� Date: �i
Receipt # Staff:
PARCEL INFORMATION Planned Development Mixed
Tax Map and .Parcel: 78-31J Existing Zoning Commercial
Parcel Owner: PJP Building Six LC
Parcel Address: Suite 290, 650 Peter Jefferson Pkwy City Charlottesville State VA Zip 22911
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Kevin Silson
Address : 1003 West Main Street City Charlottesville State VA Zip 22911
Office Phone: (434) 243-8032 Cell # 434-962-5023 Fax #434-924-7176 E-mail pks3k@virginia.edu
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name New business
Business Name/Type: UVA Primary and Specialty Care Pantops
Previous Business on this site computer software company
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: Medical clinic - 10 employees - Hours 7:00 am - 6:00 pm M -F
18 available parking spaces - 10 patients/hour
*']'his 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 n e the own 's permission to use the space indicated on this application. I also certify that the information provided
Imy
is true and accurate the kno, led I have read the conditions of approval and I and stand them, and that I will abide by them.
Signature Printed
IV
APPROVAL INFORMATION
Approved as proposed [ ] Approved with conditions [ ] Denied
[]Backflow prevention device and/or current test data heeded 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 _ Dated "
Zoning Official 4A Date 41 .
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/N
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y/N
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 u is er?
If private well, provide Hea 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 fic sew r?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
&YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # —2.5 921, A(-/
Zoning to complete the followinLY:
Reviewer to complete the following:
Square
Square footage of Use: 415 b
6i / N
Permitted as: A,, ,P �'�A I �T t i 1r�
Under Section:
Supplementary regulations section:
Parking formula:
�D A.,�
Required spaces:
Yl �j
Items to be verified in the field:
Inspector : Date:
Notes:
Violations:
Y /
If so, ist:
Proffers:
a)/ N
If so, List:
Z,'✓1 20o I /S
Variance:
Y /d
If so, List:
is:
/ N
If so, List: Z
b�
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
n
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,
was provided to
[County application name and number]
the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
Hand delivering a copy of the application to
by delivering a copy of the application in the
[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
[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
to the following address:
[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
Print Applicant Name
Date