HomeMy WebLinkAboutWPO201600007 Application 2018-09-18 Virginia StormProgram(VSMP) swater Mana ement ""`
Application for Albemarle County .
Project Names. Inglewood Terrace -. -
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes 0 No 0
Is this a revision or resubmission for review? Yes Il No
County File Number: WPO 2016-0007 : (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.
. II 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.
ie
61-10A0: Brian Gillispie (.1a1.t Y...
Tax Map&Parcel Print Name of Property Owner • Signature of caner-" .. Date
•61710A2 ... Brian Gillispie i.Z i .I81 ..
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 Owcier(s)to receive correspondence:
Print Name Brian Gillispie
Address . :: P.O.Box 513
• City Earlsyville State VA Zip 22936
Daytime Phone( ) E-mail b_gillispie@msn_com
•
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