HomeMy WebLinkAboutWPO201400071 Application 2014-08-15NNW *4 *01
Virginia Stormwater Management Program (VSMP) �t
Application for Albemarle County :,;��A•,t`
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Project Name: 01,rd -•d i' d \NWQe, OocAe I Z EM'S i on cp) gjlI yl oJ._n �s�tJl/y 'VvC�,{ ✓
(The name should be the .same as it appears on plans) rv, E' 6u')0,9re, t_-.viif 'P(fit
Is this an amendment to an approved plan? Yes ❑ No X
Is this a revision or resubmission for review? Yes ❑ Nox
County File Number:
(to be provided by the Cozrnty,for neii, applications)
The following are required elements of'new applications lfr-om 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 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. I
� - 0 1 - 01 MCAV,;," M Ut-t btnM
Tax Map & Parcel Print Name of Property
of
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 Nw e, Rro(;,y_f'Yi(`,1.,n
Address
f—ADQ 5 KaBn' Y"f :l!' a[ l [rcie, U k{ l oo
CityState n Zip 72��'�
Daytime Phone (7yZ) 90- c30i''� E-mail CAUe, tjt irLjk (Vi I aae, CyYrl
11
7/1/14, Revised: 7/10/14 Page I oft
O
on
❑ B. All Fees [Code section 17-Z08]
For new or modified plans; Total acres proposed to be disturbed
❑H
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
Registration Statement on the official DEQ form.
Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
Stormwater Management Plan satisfying the requirements of code section 17-403.
Pollution Prevention Plan satisfying the requirements of code section 17-404.
Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
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_�jj i k l j b� r R.aUC�Gt L1SI�1 �Cl [L� C�sn 1� SSUG.
Address " I 1 y M Q ah (. e h Q
City `i/)Clll(1 C1-'1'ti' S-J M-e, State Zip 2290Z
Daytime Phone (+3q) 9 7 7 — () 2 05 E-mail & tC1 be-+ er <� YoLdCI CIO( a s i1 C.00rl
*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:
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