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Home My WebLink AboutWPO201600060 Application 2016-10-03 Virginia Stormwater Management Program (VSMP) Application for Albemarle County11/11f), PP / Project Name: Region Ten Women's Shelter (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No WI Is this a revision or resubmission for review? Yes ® No ❑ County File Number: WP02016-00060 (to be provided by the County for new applications) The following are required elements of new applications(from code section 17-4011 For revisions or amendments,please indicate which items are being amended. Signatures must be provided for any submission. A. Signature of the Property 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. 76-46F Region Ten Community Services Board "� u i 1 r �:•".� Tax Map&ParceI Print Name of Property Owner S' nature of Owner Date Tax Map&ParceI Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name Kathy Williams, Region Ten Fiscal Director Address 502 Old Lynchburg Road City Charlottesville State VA Zip 22903 Daytime Phone(434) 972-1816 E-mail kathy.williams@regionten.org 7/1/14,Revised:7/10/14, 1/7/14 Page 1 of 2 WI B. All Fees [Code section 17-208] For new or modified plans;Total acres proposed to be disturbed 1.10 Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed Application modification of permit Less than 1 $290 $145 $20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 $300 50 and less than 100 $6,100 $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;$150 ® C. Registration Statement on the official DEQ form. El D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. l E. Stormwater Management Plan satisfying the requirements of code section 17-403. 66 F. Pollution Prevention Plan satisfying the requirements of code section 17-404. m G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name Alan Franklin, PE;Waterstreet Studio, LLC Address 418 East Main Street City Charlottesville State VA Zip 22902 Daytime Phone(434) 295-8177 E-mail afranklin@waterstreetstudio.net *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# Fee Amount$ Date Paid By who? Receipt# Ck# By: 7/1/14,Revised:7/10/14, 1/7/14 Page 2 of 2 Albemarle C 401 Community Development Departn McIntire Road Charlottesville,VA 22902-4! Voice (434)296-5832 Fax (434)972-4 Planning Application PARCEL I OWNER INFORMATION TMP 07600-00-00-046F0 Owner(s): REGION TEN COMMUNITY SERVICES BOARD INC Application # WP0201600060 PROPERTY INFORMATION Legal Description I ACREAGE Magisterial Dist. ' SCOtt.Sirrine V Land Use Primary Office Current AFD Not in A/F District 'r Current zoning Primary Commercial Office [APPLICATION INFORMATION Street Address 502 OLD LYNCHBURG RD CHARLOTTESVILLE, 22903 Enterer: - Judy Martin Application Type Water e Protction Ordinances E 110/4/2016 L__ Project Region Ten Women's Shelter- VSMP Received Date 10/03/16 Received Date Final Submittal Date 10/10/16 Total Fees 13 Closing File Date Submittal Date Final Total Paid L 13 Revision Number Comments Legal Ad SUB APPLICATION(s) Type Sub Application Comment Stormwater Management/BMP Plan 1 10/10/16 Erosion and Sediment Control Plan 10/10/16 APPLICANT/ CONTACT INFORMATION ContactType Name Address CityState Zip Phone PhoneCf Owner/Applicant REGION TEN COMMUNITY SERVICES BOA BOO PRESTON AVE :CHARLOi SVIL L 22903 Primary Contact KATHY WILLIAMS/REGIONA TEN FISCAL D 502 OLD LYNCHBURG ROAD CHARLOTTESVILL 22903 4349721816 Signature of Contractor or Authorized Agent Date OIc4o I.1/.li Virginia Stormwater Management Program (VSMP) Application for Albemarle County IH:ITV- Project Name: Region Ten Women's Shelter (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No 121 Is this a revision or resubmission for review? Yes ❑ No 6d' County File Number: (to be provided by the County for new applications) The following are required elements of new applications[from code section 17-4011 For revisions or amendments,please indicate which items are being amended. Signatures must be provided for any submission. ® A. Signature of the Property 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. Ter Com ail! l 76-46F C-. 9 2.60 j0 Tax Map&Parcel Print Name of Property Owner ignature of wner ate Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Tax Map&Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence: Print Name Kathy Williams, Region Ten Fiscal Director Address 502 Old Lynchburg Road City Charlottesville State VA Zip 22903 Daytime Phone(434) 972-1816 E-mail kathy.williams@regionten.org 7/1/14,Revised: 7/10/14, 1/7/14 Page 1 of2 ® B. All Fees [Code section 17-208] For new or modified plans; Total acres proposed to be disturbed I* 1 i Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed Application modification of permit Less than 1 $290 $145 $20 1 and less than 5 $2,700 $1,350 $200 5 and less than 10 $3,400 $1,700 $250 10 and less than 50 $4,500 $2,250 $300 50 and less than 100 $6,100 $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;$150 C. Registration Statement on the official DEQ form. 0 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. • E. Stormwater Management Plan satisfying the requirements of code section 17-403. ® F. Pollution Prevention Plan satisfying the requirements of code section 17-404. ® G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. ❑ H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. O J. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents: Name of a Contact Person for correspondence(usually the plan preparer,consultant or agent) Print Name Alan Franklin, PE; Waterstreet Studio, LLC Address 418 East Main Street City Charlottesville State VA Zip 22902 Daytime Phone(434) 295-8177 E-mail afranklin@waterstreetstudio.net *When applications and plans are reviewed,but not approved,and a response to comments is not received within 6 months from the date of county comments,the application will be deemed withdrawn. Applications without valid owner's signatures will not be considered valid. FOR OFFICE USE ONLY WPO# t� ((QQ\\ i/V( By 9k 1 I V 1 1 Pl FYI U t V+�V1 l�.r Ck#4U I BY Fee Amount$ J�,"�'Date Paid rr who? +J G -'j�� ceipt# V IL � SOU 1 xSCVC( \flC- 7/1/14,Revised: 7/10/14, 1/7/14 Page 2 of 2