HomeMy WebLinkAboutCLE201500199 Application 2015-12-30Application for Zoni.n Clearance
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CLE # G S — \4,�FFICE US ONLY
PLEASE REVIEW ALL 3 SHE, Check# 0 Date:
Receipt # 01516 Staff:
PARCEL INFORMATION
Tax Map and Parcel: 09100 00 00 01200 Existing Zoning_ 3?h tAi\,,.J&#,o-.0 e
Parcel Owner: Albemarle Health Care Center, LLC
Parcel Address: 1540 Founders Place City Charl ottesvi l 1 estate VA Zip 22902
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Cason Field
Address:2917 Penn Forest Blvd City Roanoke state VA Zlp 4�_
Office Phone: (540)776-7496 Cell# Fax# _ Off -mall field-Jacnnfdmfa net
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name/Type: Albemarle Healthcare Center, LLC
t/a Albemarle Health & Rehabilitation Center t3/a
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:
nursing home and rehabilitation center _ -
see building ❑ rmi. 92014-493
*niis 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 I Ira a the owner's permission to use the space indicated on this application. I also certify that the information provided
is true and ae ate t the t my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Tliaw IV '.W -p-= E0- Iv --
L-, -n e!S
FCl-- CA lr-C ^
rotes:
AL IN RMATION
d as proposed [ ] Approved with conditions [ ] Denied
prevention device and/or current test data needed £or this site. Contact ACSA, 977-4511, x117.
ical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
complies with tite site plan as of this date.
Building Official�~ Date
Zoning Official Date
Other Official Date e `L/ �rj 1
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5832Fax: (434) 9724126
Revised 7/1/2011 Page 2 of
per Stewart Wright - see building permit #2014-493
Intake to complete the following: I Reviewer to complete the following:
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
IN
ill 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 privnte well orNWWO5820
If private well, provide HesfiLDepAment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
J/ N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # 93 0 CJ
Square footage of Use; -.17 01 y
6) / N.
Permitted as: '
Under Section;
Supplementary regulations section:
---
Parking formula:
J2 Lia _
Required spaces:
Y/J
Items to be verified in the field:
Inspector : Date:
Notes:
Zoning to complete the following:
Violations:
Y
if sst.
P offers:
/N
If so, List:
2a1�—
�oM A _—
VAri nce:
Y 14,
If so``,",,ist.-
Zia:
1 N
If so, List:
z� f
Clearnnees: SDP's
�D 2-6/2 —
Revised 7/1/2013 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. Qws n/�i R i� PP�-� ►� k1*C7- C/,-w..ol,
I certify that notice of the application,
was provided to
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number
manner identified below:
the owner of record of Tax Map
by delivering a copy of the application in the
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
[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]
Oil
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
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° ` € ALBEMAKE HEALTH Arm�-
RHffM TATION CENTER
■ 1 5 ALBEMARLE COUNTY, VA
�� MEDICAL FACILITIES OF AMERICA ��
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° ` € ALBEMAKE HEALTH Arm�-
RHffM TATION CENTER
■ 1 5 ALBEMARLE COUNTY, VA
�� MEDICAL FACILITIES OF AMERICA ��