HomeMy WebLinkAboutCLE201600159 Application 2016-08-08Application for Zon' g Clearance
CLE #
OFFICE Y
PLEASE REVIEW ALL 3 SHEETS
Check # Date:
Receipt # Staff.
PARCEL INFORMATION
Tax Map and Parcel: Existing Zonftrg PD-MC
Parcel Owner: 5th Street Station Ventures LLC
Parcel Address: 250 Merchant Walk Ave., Suite 1106 Clty Charlottesville State ViMinia
Zip 22902
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Dan Tucker
Address: 5 SW Broad Street, Suite B City Fairburn State Georgia
Zip 30213
Office Phone: 7( 70) 692-8300 Cell # 434 245-4909 Fax # �770) 692-8302 E-mail dan(asicollinsent.com
APPLICANT INFORAlATION
Check any that apply. Change of ownership Change of use Change of name x New business
BusinessName/Type. Verizon / Mercantile
Previous Business on this site mostly undeveloped 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: This 2,403 square foot Verizon (mercantile)
business has
*ibis CIearance will only be valid on the parcel For which it is approved. if you change, intensity or move the use to a new location, a new Zoning
Clearance will be required.
I hereby certify that 1 own or have the ownaes permission to use the space indicated on this application. I also certify that the information provided
is true and accurate/tp,-tbc best of my knowledge. I bave read the conditions of approval,
and I understand them, and that I will abide by them.
Signature ICY Printed_ _ f 1 �, OTH `i
AL INF01ZNUTION
N Approved as proposed [ ] Approved with conditions [ ] Denied
f ] Backflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ ] 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.
Building Official
Zoning Official
Other Official
Date g
Date ZZ_Z zap
Date
County of Albemarle Department of Community Development
40111icintire Road Charlottesville, VA 22902 Voice: (434) 296-5832 Fag: (434) 972-4I26
Revised 7/1/2011 Page 2 of 3
Intake to complete the following:
Yl(6?
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y l
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 or uFepp=tment
er?
If private well, provide Hea 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 Ftfiblic sews ?
Y/N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit
Permit #
b/ N
Will there be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to comviete the following:
Reviewer to complete the following:
Square footage of Use: I D
(91 N 1
Permitted as: rc�-tq
Under Section: , 2•
Supplementary regulations section:
Parking formula: S
Required spaces:
Y/
Items to be verified in the field:
Inspector • Date:
Notes:
Violations:
�' l�
Ifs r
roffers;
� / N
If so, List:
d
��--
Variance.
Yl
If so t:
SP"s:
YI v
If so, List:
Clearances:
SDP's
Revised 7/1/2011 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.
I certify that notice of the application, Application for Zoning Clearance - Veriz_on
[County application name and number]
was provided to 5th Street Station Ventures, LLC - Dan Tucker the owner of record of Tax Map
[name(s) of the record owners of the parcel]
and Parcel Number by delivering a copy of the application in the
manner identified below:
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
X Mailing a copy of the application to 5th Street Station Ventures, LLC - Dan Tucker
[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 06-28-16 to the following address:
Date
5 SW Broad Street Suite B Fairbum GA 30213
[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