HomeMy WebLinkAboutWPO201400071 Preconstruction FormRequest for Pre-+ onstruetion Meeting and Grading Permit s y
from Albemarle County
Approved Plan Number: WPO-(��
Approved Plan Name: Q cx` - j k i a ct i- CMcl
(Plans must be approved prior to a pre -construction meeting.) P ¢�
Bond approved date:
(Bonds must be approved and posted prior to a pre -construction meeting or permit.)
Responsible Land Disturber: i?
Print Name: S co l f' B r end S h cfi-y�l ` AC D 0LLAKO
State Certification Number: oC`7
Address
City 710s1 State VA Zip —qQ-9--1q
Daytime Phone (_) 3-7 S Q E-mail S (n tt' v c q C� t k� &-V` d% C G fn
Primary Contractor:
Print Name A C� Vi i 1 CLY- A
Address
City
StateVA Zip_ o
Daytime Phone(__) �]� - ?y 5 Cj E-mail`. C clAA ' ciad t t 1 Ul YA • C 0 f Vl
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Permit Issuance andTirst Year Maintenance Fees: (Request must include payment)
Total acres proposed to be disturbed is contained on the approved plan and application:
VSMP:
Acres to be disturbed
Fee Due at Grading Permit
Less than 1 ;
$63.80
1 and less than 5
$594.00
5 and less than I0
$748.00
10 and less than 50
$990.00
50 and less than 100
$1,342.00
100 and more
$2,112.00
For plans exempt from VSMP, VESCP fees were paid with the application.
7/1/14, Revised: 8/29/14 Page 1 of
Person(s) to attend the Pre -construction Meeting:
Names (type or print) Firm Contact Number or email
c r;N � c15 �ta b i A-C, 0 ac.1 d I I I t ard ryN
F
The second part of'the application fee is required to be paid with this request. This fee amount is;
FOR OFFICE USE ONLY Permit Issued Date
By who?
7/1/14, Revised: 8/29/14 Page 2 of