HomeMy WebLinkAboutCLE201600154 Application 2016-07-14R `•
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PARCEL fNFORMAUX)IN
Tax Map and Parcel: -_ '- 't;xi ang za►nin _
Psrcel Owner. SouthernCare Inc
941 Glenwood Station Lane, Unit 204 . t�, Charlottesville L, ,,t :VA 22901
ro ` y 1113A1 AC SouthernCare Inc, C/o Business Licenses, LLC — ¢
Who should we cali/write concerning thi3 pro �Lt? — _—
Address;POB 8000 City Monsey _ 3t NY - Zit10952
aiiilcs 1'1$ond. �45_ 56-8390 x127 Cell 4 Fax 0 polatseckm@businesslicenses.com
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i:, sicsa an4a p , SouthernCare Inc- Hospice Agency��-
Previous Business on this site
.1 Describe the proposed business Including use, number of employees, number of shifts, availabl arming spaces, number of I
vehicles, and any additional information that you can provide: 7 Employees, total SF=2,24l i
"'Th1: C,e,rtww;; ';Vjli caly N , rlici r,r. ;1hv purvet for Which it is ap wry :d. if Vou char; r, i our €iy or muNv Vlk; u c: to a n�es� i z ;, s3, a aa., x Z'-'nniq
�'lr i:C7s'b� �kal CC rW!�uhs.�.
i [ hereby certify that I own or have the owner's permission to use the space indicated on this application, I also certify that the information provided
is true and aectui to to the beat of my knowledge. i have read the conditions of approval, and I understand them, and that I will abide by them.
Sim-atu-;e 7YA& oeata�ck ?:in' ciMatt� Polatseck _.._
2ITZOVAL I IsoRP,11AT 1011
Approved as proposed [ ] Approved with conditions [ ] Denied
] Backflow prevention device and/or current test data needed for this site, Contact ACSA, 977-4511. x117.
[ ] No physical site inspection has been done for this clearance. Therefore, it is not a determination of compliance with the existing
site plan.
[ ] This site complies with the site plan as of this date.
Notes: -- - - ------ _
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Building Of clal __- _. Putt
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Zoning Official ".te 7 --
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Other Official
4l3.13.T t":.'�ti?�5e},;p., itl?„=s"t3diiF: 1E4..'i33i1.FAtiFsta$,`Y
401 _i�e1n:°i:e it�.af�1t1•z,-�i�, ash-�'ta"4c�ii.�� ��ai) _� :', #? >';r ti: (434) 972-4126
Revised 11/1/2015 Page 2 of 3
Intake to complete the following'
Y / lb
Is use in LI, HIor PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y 1
Will ffiere be fond preparation?
ff 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 r pWvra r?
If private well, provide th Do en# form.
Zonin; review can not begin until we receive approval firm Health
Dept, FAX DATE
Circle the one that applies
Is parcel on septic or p ie sever?
YIN
Will you be putting up a new sign of any hind? If so, obtain proper
Sign permit,
Permit #
YIN
Will there be any new construction or renovations?
If so, obtain the proper Permit,
Permit #
Reviewer to complete thQ following:
Square footage of Use:
(OIN
Permitted as.
Under Section. -
Supplementary regulations section:
Parking formula:
Required spaces:.
Items to be verified in the field:
Inspector
Notes:
�Jlfi.i �Ifl iV 4Via� ■Barr aaas . v*r raa
Violations:
Y I �
If so, st:
,P filers:
N
FIN
If so, List: %
Vari ce:
Y1
If so, List:
Y/
If so, List:
Cte:� ramces:
SDP's
Revised I I I 2015 Page 3 bf 3
x
CERTIFICATION ` `HA NOTICE OF THE
:f PPLICAT'I iN HAS BEEN PROVIDED TO THE LANDOWNER
This form must accompany zoning apphcati'ons (.Horne occupation, Zoning aearauce, Zoning
Admfnislrator Determinations arAppeals, Si P Permits, Building Permits} if the application is not the
owner.
I certify that notice of the application,
was provided to
SouthernCare Inc
[County application name and .number]
[name(s) of the rid 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 appiication 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
Mailing a copy of the application m C/o Business Llcanaes, LLG POB 8D0D, Nbnsey, NY 70952
[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
5^!.
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 test assessment records satisfies
this requirement].
Signs re ofApplican*
Matyt Polatseck
6/21 /2016