HomeMy WebLinkAboutCLE201600029 Application 2016-02-128
Application for Zoning Clearance
CLE # a4,`o — 015;'0 P-9
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PLEASE REVIEW ALL 3 SHEETS
OFFICE USE ONY
Check # c?346 4 ,?.311 Date: 2 ' 9-J.0 /lo
Receipt # le,9 i 3 7 f�- Staff:
PARCEL INFORMATION 0 -3; 3 a
Tax Map and Parcel: 45C-2-300 Existing Zoning PSSC
Parcel Owner: Henry J Favor
Parcel Address: 1849 Seminole Trail City Charlottesville State VA Zip 22901
(include suite or floor)
PRIMARY CONTACT
Who should we call/write concerning this project? Caryl Purcell
Address: 11518 Cedar Lane City Ashland State VA Zip 23005
Office Phone: (§04) 368-0612 Cell # Fax # E-mail caryl.pureel l@amelia licensing. cdo
APPLICANT INFORMATION
Check any that apply: X Change of ownership Change of use Change of name New business
Business Name/Type: 7 -Eleven 11 136K, retail convenience
Previous Business on this site 7 -Eleven 11136G
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. 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 to'the pbest ,of my knowledge. I have read the conditions of approval, and I understand then, and that I will abide by them.
Signature l� u.e.�(/C Y"�(.IJ�CX� Printed Caryl Purcell
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 a c
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 7/1/2011 Page 2 of
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.
G%/ N
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 wellublic water's
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 ap l
Is parcel on septic ublic sewer
Y l
Wiltyou be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y /
t
Wil ere be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Znninor to cmmnlete the following_
Reviewer to complete the following:
Square footage of Use: a
iitted as: ko Tibac—
Under Section:
as. a. r
Supplementary regulations section:
Parking formula:
rOss
Required spaces: �a
IN I
Items o be verified in the field:
Inspector:
Notes:
Date:
Violations:
YIN
If so, List:
Proffe s•
Y1
If so, List:
ariance:
IN
If so, List:
SP's,:�
Y/[NJ
If so, ist:
Clearances:
SDP's
Revised 7/1/2011 Page 3 of 3
�v
22T
7 -ELEVEN
1;� . o .il S70R6 # 11136
1849 SERMNOLE TRAIL
I C 4ARLOTTES LLE, VA 224301-1129
01
POWER OF ATTORNEY
Know all persons by these presents that 7 -Eleven, Inc. ("7 -Eleven" or the "Company'), has
made, constituted, and appointed, and by these presents does hereby make, constitute, and
appoint Caryl Purcell of Amelia Licensing, LLC:
Its true and lawful aftorney-in-fact, for it, and in its name, place, and stead, to take all actions
necessary and appropriate to apply for and obtain any licenses, permits or similar services
incidental to the business of the Company in Maryland, the District of Columbia. Virginia and
West Virginia only including, but not limited to, the following categories:
• alcoholic beverages;
• lottery;
• tobacco;
• food processing;
• food service;
• food products/retailing;
• volatile chemical; and
• utilities.
Also included are any and all otner documents relating to or necessary for the issuance or
transfer of such licenses, including but not limited to guarantees to the licensing agency, and to
assign and reassign any and all necessary papers in connection therewith, giving and granting
unto its said attorney-in-fact full power and authority to do and perform all and every act, as to
all intents and purposes as it might or could do, with full power of revocation, hereby ratifying
and confirming all that its said attorney-in-fact shall lawfully do or cause to be done by virtue
hereof.
The individual appointed as an attorney-in-fact herein shall remain an attorney-in-fact with the
authority granted herein for until such appointment is otherwise revoked by 7 -Eleven.
In witness whereof, said 7 -Eleven has caused these presents to be signed by its proper
corporate officer as of August _e -Z 1 2013.
7 -ELEVEN, INC.
Attest:
By:
A#WE. R-ubinettl Rankin L. Gas ay
Ass Stant Secretary Senior Vice President
177658x13
State of Texas
County of Dallas
On this _c2 I day of�...�, 2013, before me, the undersigned notary
public, personally appeared Rankin L. Gasaway and Arthur E. Rubinett a Senior Vice President
and an Assistant Secretary, respectively, of 7 -ELEVEN, INC., a Texas corporation, known to me
to be the persons whose names are subscribed to the foregoing instrument, and acknowledged
to me that the same was the act of the said corporation and that they each executed the same
as the act of such corporation for the purposes therein expressed and in the capacities therein
stated.
In witness whereof, I hereunto set my hand and official seal.
�C e�
(Nota Public sig'Mture)
(typed or printed name)
17765803
(SEAL)
: Karen Pennell
Ft 4 Mvfery Pub, State of To=
_ *.
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