HomeMy WebLinkAboutWPO201700070 Application 2019-01-29,x Al.���
Virginia Stormwater Management Program (VSMP) - , II
Application for Albemarle County
J 'f ;A, �
Albemarle County Route 250 Business (Ivy Road) Sidewalk
Project Name: _(County Administered Revenue Sharing Project)
('The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No
Is this a revision or resubmission for review? Yes ® No ❑
County File Number: WPO 2017 00070 (to be provided by the County for new applications)
The following are required elements of new applications Lfrom code section 17-401]. For revisions or
amendments, please indicate which items are being amended. Signatures must be provided for any
submission.
® A. Signature of the Prol2erty Owner for each parcel: (Required with every submission or revision, NOT
TO BE SIGNED BY AN AGENT OR CONSULTANT)
By signing this application as the owner, I hereby certify that all requirements of these plans and permits will be
complied with, and I have the authority to authorize the land disturbing activities and development on the subject
property. I hereby grant the County of Albemarle the right to enter upon the property as required to ensure
compliance with the approved plans and permits.
Public Rights -of -way and Easements held by the
County of Albemarle ?,Jl q
Tax Map & Parcel Print Name of Property Owner ignat 1 e cYf Owner to
Tax Map & Parcel Print Name of Property Owner Signature of Owner
Tax Map & Parcel Print Name of Property Owner
Tax Map & Parcel Print Name of Property Owner
Contact Information for the Owner(s) to receive correspondence:
Print Name Jack M. Kelsey, PE - Transportation Engineer
Signature of Owner
Signature of Owner
Address County of Albemarle, FES Project Management Division, 401 McIntire Road
City Charlottesville State VA
Daytime Phone ( Ext 3376 E-mail jkelsey@albemarle.org
Date
Date
Date
Zip 22902
7/1/14, Revised: 7/10/14, 1/7/14 Page 1 of 2
NA ❑ B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed
Acres to be
Total Fee
Fee Due with this
Fee with Transfer or
disturbed
Application
modification of permit
Less than 1
$290
I $145
$20
1 and less than 5
$2,700
I $1,350
$200
5 and less than 10
$3,400
I $1,700
$250
10 and less than 50
$4,500
I $2,250
$300
50 and less than 100
$6,100
I $3,050
$450
100 and more
$9,600
$4,800
$700
For (minor) amendments to an approved plan; $200 per review
Variances; $150 (per request)
Mitigation Plan; $150
❑ C. Registration Statement on the official DEQ form.
0 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
0 E. Stormwater Management Plan satisfying the requirements of code section 17-403.
❑ F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
❑ G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
NA ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
NA ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408.
NA ❑ J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the
requirements of code section 17-422.
Provide 2 copies of all plans and any supporting documents. Professional seals must have original
signatures.
Additional information if not provided on plans and documents:
Name of a Contact Person for correspondence (usually the plan preparer, consultant or agent)
Print Name Brian McPeters, PE
Address Kimley-Horn and Associates, Inc., 1700 Willow Lawn Drive, Suite 200
City Richmond
Daytime Phone 8( 04) 672-4721
State VA Zip 23230
E-mail brian.mcpeters@kimley-horn.com
*When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 months
from the date of county comments, the application will be deemed withdrawn. Applications without valid owner's
signatures will not be considered valid.
FOR OFFICE USE ONLY WPO #
Fee Amount $ Date Paid By who? Receipt # Ck# By:
7/1/14, Revised: 7/10/14, 1/7/14 Page 2 of 2