HomeMy WebLinkAboutCLE201500251 Application 2015-12-17Application for Zoning Clearance
CLE # DO 1 a.S
OFFICE USE ONLY
PLEASE REVIEW ALL 3 SHEETS Check# 'o��cx�13S-"tom Date: �r
Receipt # )!=a � - Staff: S
PARCEL INFORMATION
Tax Map and Parcel: 06100-00'00-14700 Existing Zoning_
Parcel Owner: TAYLOR DEVELOPMENT GROUP, LLC
101. �:o zz C Gv� IL-� VA aa9cq
Parcel Address: City IAkmkx-S� Stater Zip X9-3,
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? CIRCLE K STORES INC
Address: 305 GREGSON DRIVE City CARY State NC Zip 27511
Office Phone:9( 19) 774-6700 Cell # Fax # 919-718-0291 E-mail csloop@circlek.com
APPLICANT INFORMATION
Check any that apply: X Change of ownership Change of use Change of name New business
Business Name/Type: CIRCLE K STORES INC/DBA: KANGAROO EXPRESS#2723206
Previous Business on this site CONVENiENCE/RETAILIGAS
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: 5-10 employees, available parking,retail merchant,
r ONVEN.I.E.N.CEIRETA111GAS
*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 o is permission to use the space indicated on this application. I also certify that the information provided
is true and ac ate est of lm d e. I have read the conditions of approv , d I understagd them, and that I will abide by them.
U �
Signature t Printed
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
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:
YIN
Is use in LI, HI or PDIP zoning? If so, give applicant a Certified
Engineer's Report (CER) packet.
YIN
Will there 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 public water?
If private well, provide 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 septic or u is se er?
Y1
Will ou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Yl
Willie be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zonine to complete the following:
Reviewer to complete the following:
Square footage of Use: /-70(9
®IN
Permitted as: _ 4,;ij
Under Section: _ 7-f�- Z'`
Supplementary regulations section:
Parking formula:
Required spaces:
YIN
Items to be verified in the field:
Inspector
Notes:
Date:
Viola ons:
Y/
If so, ��rist:
Proffers:
Z/N
If so, List:
Variance:
Y/
If so, ist:
SP's:
0/N
If so, List:
Clearances:
SDP's
Revised 11/1/2015 Page 3 of 3
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