HomeMy WebLinkAboutCLE201700195 Application 2017-08-27Application for ZoningClearances
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PLEASE REVIEW ALL 3 SHEETS
OFFICE U QI�I�Y
Check # / 1 Date:
Receipt # 0 0 `2t4 Staff:
PARCEL INFORMATION
Tax Map and Parcel: 061 WO-01-OA-009130 Existing Zoning C1
Parcel Owner: PMJB Land Trust
Parcel Address: 2340 Commonwealth Drive City Charlottesville State VA Zip 22901
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Sue A. Albrecht
Address : 340 Greenbrier Drive City Charlottesville State VA Zip 22901
Office Phone: ( 434) 973-6161 Cell # 434-531-2435 Fax # 434-973-0732 E-mail sue@designenvirons.com
APPLICANT INFORMATION
Check any that apply: Change of ownership Change of use Change of name X New business
Business Name/Type: Health Connect America, Inc.
Previous Business on this site Parker, McElwain, & Jacobs
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:
Family COWR66"Ag, 4 orAployees, 1 Shift, AG GQMPaAy vehicles, 38 spartas available
parkipg
*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. I also certify that the information provided
is true and accurate o the best wledge. I have re the conditions of approval, and I understand them, and that I will abide by them.
Signature Printed Sue A. Albrecht
APPROVAL INFORMATION
>41 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 �/ V?
Zoning Official Date
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:
Reviewer to complete the following:
Y / N Square footage of Use: 233 J
Is us n LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet. / N
ermitted as: AX, ,,�
Y / `[h Will ere be food preparation? Under Section:
If so, give applicant a Health Department form.
Zoning review can not begin until we receive approval from Health Supplementary regulations section:
Dept. FAX DATE
Circle the one that applies
Is parcel on private well or �water?If private well, provide Healthform.
Zoning review can not begin until we receive approval from Health
Dept. FAX DATE
Circle the one that applies
Is parcel on septic or blic sewer?
Y /
Will u be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y//Fj
Will ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Parking formula:
Required spaces:
Y/N
Items to be verified in the field:
Inspector:
Notes:
Date:
Violations:
Y/N
If so, List:
Proffers:
Y/6l
If so, List:
Variance:
Y/N
If so, List:
SP's:
Y/J
If so, List:
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, Zoni
was provided to Anvince Land Trust
Clearance
[County application name and number]
[name(s) of the record owners of the parcel]
and Parcel Number 061WO-01-OA-009B0
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 application to Anvince Land Trust
[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 08/19/2017
Date
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
Date
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].
Sue A. Albrecht
Print Applicant Name
08/19/2017
Date