HomeMy WebLinkAboutCLE201600046 Application 2016-03-09Application for Zonin Clearanceit-
OFFICE
CLE # 2a1 4o - USE ONLY ?p7
PLEASE REVIEW ALL 3 SHEETS Check # Date: 3 r (o
Receipt # 1 O 3333 Staff..
PARCEL INFORMATION
Tax Map and Parcel: 046B-00-00-001 Al Existing ZoninpCom For Business or Retailing
Parcel Owner -Michael Kohn
Parcel Address: 1769 Worth Park, Suite B City Charlottesville State VA Zip 22911
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? John Gandy
Address :3350 Baybrook Drive City Rockingham State VA Zip 22801
Office Phone:9( 10) 603-4634 Cell # same Fax # E-mail jhgandy@aol.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name/Type: New Image Body Sculpting, LLC Medical/Healthcare
Previous Business on this site IT 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:
Health, wellness, weight loss, nutrition. 2 employees 9-5 Mon -Sat, 12+ Parking spaces, we will have 1-3 clients in the
building at a time. _
*'Phis 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 the best of my knowledge. I have read the conditions of approval, and Iunderstand them, and that I will abide by them.
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Signatur:'' ' Printed �Ire 11Y L-� _1'V
APPROVAJINFORMATION
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 '3/� c [� - -• Zoning Official Official du/ Date
Other Official Date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 22902 Voice: (434) 296-5532 Fax: (434) 972-4126
Revised 11/02/2015 Page 2 of 3
Intake to complete the following:
IsI
Is ustriff LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Will 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 oublic water
If private well, provide Heat _e$ ment 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 public sewer?
Y /(1
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/N0
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the followine:
Reviewer to complete the following:
Square footage of Use: —/ 1/00
Y/N jOn
Permitted as: _A01%A f 6.4) ce- ^
Under Section: 2-�%. Z, !
Supplementary regulations section:
Parking formula:
Z -0A .N4
Required spaces:
YI
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/�}
If so, ist:
Proffers:
Y/
�
If so, ist:
Varian e:
Y/ IV
If so, List:
SP's:
Y/?
If so, ist:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
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