HomeMy WebLinkAboutCLE201600111 Application 2016-05-13Application for Zoning Clearance �"
CLE # 1 ��
OFFICE USE ONL
PLEASE REVIEW ALL 3 SHEETS Check # 20am Date:
Receipt # Staff.
PARCEL INFORMATION
Tax Map and Parcel: 076M1-00-00-002B0 Existing Zoning_PDSC _
Parcel Owner: 5th Street Station Ventures, LLC
Parcel Address:149 Brent Creek Parkway _ City Charlottesville State VA Zip GA
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Nicholas Tyson/Select PT
Address. 680 American Avenue City King of Prussia State PA Zip 19406
Office Phone: 6( 10) 992-7135 Cell # Fax # (610) 265-8821 E-mail _pt(son5@verizon.net
APPLICANT INFORMATION Select Physical Therapy
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name/Type: Select Physical Therapy/Outpatient Physical Therapy Clinic
Previous Business on this site None
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:
.hnnnt
20
*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. 1 also certify that the information provided
is true and accurate to the best of my knowledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
Signature J _ _ _ Printed Nicholas Tyson
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 �' r G
Zoning Official Date �&�Z
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 11/02/2015 Page 2 of 3
Intake to complete the following:
Is u-in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y l
WiII re 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 public w r?
If private well, provide He artment form.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that appli
Is parcel on septic or ublic sewe
YIN
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit1#
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the followine:
Reviewer to complete the following:
Square footage of Use:
+SCIN
Permitted as: AAA i p ig'✓
Under Section: _ 7---
Supplementary regulations section:
Parking formula:
/oL�
Required spaces:
Items to be verified in the field:
Inspector :
Notes:
Date:
Violations:
Y/0
If so, List:
offers:
W1N
If so, List:
A
Varia ce:
Y/V
If so, List:
SP's-
Y/
If so, ist:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
Select physical Therapy
V Street Station
EXHIBIT A
PROPOSED
®
TENANT FURNISHED/
CONTRACTOR INSTALLED
EQUIPMENT
1
HOT PAK
2
COL PAK
3
WASHER
4
DRYER
5
REFRIGERATOR
6
MICROWAVE
7
FLUIDOTHERAPY
8
SPLINT PAN
9
PARAFFIN
O
CONTRACTOR PROVIDED
EQUIPMENT/FIXTURES
A
WATER HEATER
B
TWO LEVEL DRINKING FOUNTAIN
C
WALL MOUNT HAND WASH SINK
& FAUCET
D
COUNTERTOP MOUNTED SINK &
FAUCET
E
MOP RECEPTOR & FAUCET
F
WASHER BOX
G
CUBICLE CURTAINS
H
WATER CLOSET
J
PASS—THRU WINDOW
K
MIRROR WALL & BALLET BAR
,�,SicttL
00, ��� � � � PAP-
SK-5 — PROPOS N
SCALE: 7 8" = l'—O" USABLE A A: 1936SF
Project No.: 1Robert J Tana RA
Dote: 4/18/18/16 SELECT PT yt
Designed By:
Drown By: Archita tu,e Planning Inlviur DWgn Pmjecl Ma-gament
5TH STREET STATION
90 American Ave Suite 200
Sheet SHOPS 1 1 OD Ning Of Pru991g, PA 19406
(610)
No, CHARLOTTESVILLE, VA 22902 Foe: (6110)9265 SE21
ntyson5o•reAxon.net