HomeMy WebLinkAboutCLE201600271 Application 2016-12-13Application ninClearance 0111z.
CLE ,
CCIPPIC iINL
PLEASE REVIEW ALI, 3 SETS Check ## J� Date:
Receipt # staff:
PARCEL INFORMATION
` '�___....__. J �
fax Map and Parcel: �a `�' �2 — _ / � Existing Zoning
Parcel Owner: C,4,A ,b 1. L_! _/L
' Parcel Adrlress:.____/y� �ckt _CL��d C;ztyC %Arrs�' ; //�ta8e !J .<i _ Zip
(include suite or Borer)
PRIMARY CONTACT
Who should we call/write concerning this project'
Address : ��� 9 _ act t Srti� .�ze._ 7f,'i-- citv �•. �/ Mate Zip
Office Phoney (�� 3 S� /(Cell# Fax _E-mail
APLICANT N ORIMAT ON
Check any that apply. Change of rwnership-- �i�ange of use Change of name New business
Business Nsme/TType:,I /.zfr'_.�....�.
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:
"This Clearance will only be valid on the parcel for which it is approved. Ifyou charge, intensify or move the use to a new location, a new onin-g
Clearance will he 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 �xf rn wledge. % ve read the conditions of approval: and I understand them, and that I will abide by them.
Signature �� � �� .. 7;7Printed
_._... � ._ — _----- ----- - .._....
Aff�, INROVAL'O. ATIO '
Approved as proposed [ ] Approved with conditions [ ] Denied
rBackflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, xl 17.
[ 3 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:
.._........ ..... ..................... .. . . .. _ .. _ ___..._.__............... .......... w.....
Official fate
_ ._.
j
Zoning Official Elate
Other Official date
County of Albemarle Department of Community Development
401 McIntire Road Charlottesville, VA 229€I2 Voice: (4 4) 296- 5332 F= (434) 972-4126
Revised i l/l/2015 Page 2 of 3
Intake to complete the following:
Y
Is use in LI, I -II or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
Y /
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 w ublic er?
p-R or ic If private well, provide CIPEpartment form.
Zoning review can not begin until we receive approval from Health
Dept- FAX DATE------
Circle the one that ap��
Is parcel on septic or fublic sewer?,/
Y / N
Will you be putting up a new sign of any kind?
Sign permit.
Permit #
If so, obtain proper I
t / N
ill there be any new construction or renovations?
If so, obtain the proper Permit.
Permit # 01/� — / 6 Y j\
�M
Square footage of Use: 4
/,N
Under Section:
Supplementary regulations section:
Parking formula: /
�5J /V�t
Required spaces:
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y ,
If sot:
,
Ff"roffers:
/ N
qso, List:
n� Y I
varide:
If so, List:
N
Y
If so, r-ist;
Clearances-
SDP's
Revised 11/1/2015 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, /-7
[Cdurify application name and number)
was provided to (- /,,, V,- s 1, ; / / e, �%
/ 4�2f �,e- the owner of record of Tax Map
[name(s) of the record owners of the parcel] a- L-
and Parcel Number
manner identified below:
by delivering a copy of the application in the
Hand delivering a copy of the application to 4 Z"Il 't b G, / -,,, -/r, r 2- Z- G
rNarne of the record owner if 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)
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]
on
RM
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].
:Sia;tdre,/6fAppfi ant
Print Applican4tarne
Date
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PROJECT REVISIONS:
nrLE: TENANT UP -FIT PLAN N0. I DESCRIPTION DATE
D ALLERGY PARTNERS 5 NURSES STATION/HALL DIMS 08-4s16 Dominion
A 1415 ROLHIN COURT, SUITE 102 6 PHYS.DICTATION AREA 03-30-16 a: Engineering
ro ] SHOT ROOM CAB. /NURSES STOR 05-10-18
- O SHEET TITLE: 8 CABINET LAYOUT 05-1&18 •o qe :y.:an�acei9m
TENANT PLAN SCALE: ORAWNBY: CHELKEDBY:
114• = r-0• SW ,