HomeMy WebLinkAboutCLE201800006 Application 2018-01-29S
Application for Zonin Clearance=�°�A
CLE # �
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OFFICE USE ONLY n
PLEASE REVIEW ALL 3 SHEETS
Check# Date: �i
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Receipt # Staff: D U
PARCEL INFORM ION Q�r
Tax Map Parcel: (Z1 66-0-030674 H C,
and "' Existing Zoning
r
Parcel Owner: l s Q6r A)d
Parcel Address: 3`455 Sely in61E Triad city G'It.�r�p1f'ESUI1'1� State Ui% Zip_a0g1r
(include suite or floor)
PRIMARY CONTACT (� / ��Ui CE l/
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Who should we call/write concerning this project?
Address : !I519 e6d6r 46AF_ City Ash16,11U State OA' Zip
Office Phone: M) , 0G' 06Q Cell # �-'Llq_-R - Fax # -' E-mail porw((a
APPLICANT INFORMATION
Check any that apply: X Change of ownership Change of use Change of name New business
Business Name/Type: retail convenience with gasoline
Previous Business on this site retail convenience with gasoline
Describe the proposed business including use, number of employees, number of shifts, available parking spaces, number of
ve icles, and an additional information that you can p ovide: I"� t / fCh6Ar, � EM 03 a
8 FE U1ar c rkin s E,S c r i o �r
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*This Clearance will only be valid on tlQ 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 thbest of my krlqwledge. I have read the conditions of approval, and I understand them, and that I will abide by them.
ji
Signature IIV Printed Mohan Karki
AP OVAL INFORMATION
[ ved as proposed [ ] Approved with conditions [ ] Denied
[ ] ckflow prevention device and/or current test data needed for this site. Contact ACSA, 977-4511, x117.
XNo
[ 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 OVADate Z 6�
i )
Other Official. '% Date /X'?
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:
Y
Is use m LI, HI or PDIP zoning?
Engineer's Report (CER) packet.
If so, give applicant a Certified
Y/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 well o ublic 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 appI'
Is parcel on septic o public sewer?
Y /�N
Will you be putting up a new sign of any kind? If so, obtain proper
Sign permit.
Permit #
Y/Q
Willre be any new construction or renovations?
If so, obtain the proper Permit.
Permit #
Zoning to complete the following:
Reviewer to complete the following:
Square footage of Use: y l S ,J
Pmit erted as: C 0 AV Q N Fry P, 5-toy,
Under Section: 2 q . Z.C -7
Supplementary regulations section:
Parking formula: i P I9
Required spaces:
Y N
It be verified in the field:
Inspector : Date:
Notes:
ctnan�C. o� c��N�1��sti+p Ord�
Vions:
Y' L'
If so, ist:
Proffers:
Y/N
If so, List:
Variance:
Y 0
Ifs , List:
s-
Y
SP'&Pt:
If
Clearances:
CLf
SDP's
S��cil— 7
ICI?q 1
Revised 11/1/2015 Page 3 of 3
M
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
[County application name and number]
was provided to 1 14&C rU6J COrnPanc, the owner of record of Tax Map
[nam (s) of the record owner4of the parcel]
and Parcel Number 0 3 ark -06 "0 ' 36 r-lJ by delivering a copy of the application in the
manner identified below:
0 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
Mailing a copy of the application to iku l s, sk. 6yis ml -MCc 11.a4u
[Name of the record owner if the record owiYer 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 to the following address:
Date
30 80 1467, CWdo ff9SOXc, UA aa961
[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].
Wg—fiature of Applicant
Mohan Karki
Print Applicant Name
12/20/2017
Date
. V 1113204233.1Iry5
A
1025538 - CHARLOTiESVILLE, VA - EQUIPMENT LAYOUT 1
1 FRC:F? R.^.-AD R_ :L1A N.GtE TRAIL
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Lease Agreement — B-2
13353738v.1/35045-000563
AMELIA LICENSING, LLC
11518 Cedar Lane . Ashland • Virginia 23005
804-368-0612 office/fax
December 20, 2017
RE: Power of Attorney for Ohm Shibaya LLC
To Whom It May Concern:
I, Mohan Karki, Manager Member of Ohm Shibaya LLC., hereby authorize Caryl
Purcell, Ronald Maupin, and/or Neal Seay to act on my behalf to apply for, certify,
obtain, or perform other processes to acquire all required licenses for my business,
7-Eleven 35272A, located at 3455 Seminole Trail, Charlottesville, VA 22901-5637.
This authorization is effective as of the date of this letter and will be void after June
30, 2021.
Ohm Shibaya LLC
By: -
Name: ohan arki
Title: Manager Member and Franchisee
Commonwealth of Virginia
City of Richmond
Subscribed and sworn to (or affirmed) before me this 201h day of December, 2017,
by Mohan Karki, personally known to me or proved to me in the basis of
satisfactory evidence to be the person who appeared before me.
Khaled Khashroom Stamp
Signature of Notary
My commission expires on July 31, 2018
Registration Number 7591230
AMELIA LICENSING, LLC
111518 Cedar Lane • Ashland • Virginia 23005
804-368-0612 office/fax
January 4, 2018
County of Albemarle Dept of Community Development
401 McIntire Road
Charlottesville, VA 22902-4579
To Whom It May Concern,
The 7-Eleven Store located at 3455 Seminole Trail will become be franchised on
March 16, 2018.
I have attached a completed zoning application, a floor plan, my power of attorney,
and a check for $54.00.
If any additional information is required, please contact me at 804-368-0612 or
carol.purcell'a?amelialicensin$!.com.
We would like to pick up the approved zoning clearance if at all possible.
Thank you for your assistance,
Caryl Purcell
Licensing Specialist
Amelia Licensing LLC
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