HomeMy WebLinkAboutWPO201700070 Application 2019-10-17 (2)Virginia Stormwater Management Program (VSMP)
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Application for Albemarle County
Albemarle County Route 250 Business (Ivy Road) Sidewalk
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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 0
Is this a revision or resubmission for review? Yes 0 No ❑
County File Number: WPO 2017 00070 (to be provided by the Countyfor new applications)
The following are required elements of new applications (from code section 17-401]. For revisions or
amendments, please indicate which items are being amended. Signatures must be provided for any
submission.
0 A. Signature of the 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. Jack M • Digitally signed by Jack M. Kelsey
DN: cn=Jack M. Kelsey, o=FES -
Facilities Planning & Construction,
Public Rights -of -way and Easements held by the ou=County of Albemarle,
County Albemarle of Kelsey email=jkelsey2@albemarle.org, c=US
Date: 2019.10.15 1613:47-04'00'
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel
Print Name of Owner
Signature of Owner
Date
Tax Map & Parcel
Print Name of Owner
Signature of Owner
Date
Tax Map & Parcel
Print Name of Owner
Signature of Owner
Date
Contact Information for the Owner(s) to receive correspondence:
Print Name .lack M. Kelsey, PE - Transportation Engineer
Address County of Albemarle, FES - Facilities Planning & Construction, 401 McIntire Road
City Charlottesville State VA Zip 22902
Daytime Phone ( ) Ext 3376
jkelsey2@albemarle.org
Revised 07/24/18 Page 1 of 2
NA ❑ B. All Fees [Code section 17-208] (NOT APPLICABLE)
For new or modified plans; Total acres proposed to be disturbed
Acres to be
disturbed
Total Fee
Fee Due with this
Application
Fee with Transfer or
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
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 (804) 672-4721
VA
E-mail brain.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:
Revised 07/24/18 Page 2 of 2