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HomeMy WebLinkAboutWPO201800004 Application 2017-12-15 • • Virginia Stormwater Management Program (VSMP) Yy Application for Albemarle County = ; Project Name: Free Bridge Office (The name should be the same as it appears on plans) Is this an amendment to an approved plan? Yes 0 No EU Is this a revision or resubmission for review? Yes C] No EC County File Number: not yet assigned (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. l 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,]C hereby certify that all requirements of these plans and permits will be complied with,and I have the authority tu 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. TMP 78-11A1 F&S Financial Marketing Tax Map&Parcel Print Name of Property Owner Signature f Owner Date 1 .7TMP 78-57B Free Bridge Auto Sales)i - s /.;ri s 1 Tax Map&Parcel Print Name of Property Owner ignature of wner 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 Chip Fadeley Address 1400 Richmond Road City Charlottesville State VA Zip 22911 Daytime Phone(434) 296-0006 E-mail fbasl0@ntelos.net 7/1/14,Revised:7/10/14, 1/7/14 Page 1 of 2 , I All fees have been paid with SWPPP submittal to be ® B. All Fees [Code section 17-208] confirmed by Geoff Elsie upon submittal For new or modified plans;Total acres proposed to be disturbed 1.16 Acres to be Total Fee Fee Due with this Fee with Transfer or disturbed Application modification of permit Less than l $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 1 C. Registration Statement on the officia DEQ form. 2 D. Erosion and Sediment Control Plan s tisfying the requirements of code section 17-402. ® E. Stormwater Management Plan satisf ing the requirements of code section 17-403. ® F. Pollution Prevention Plan satisfying he requirements of code section 17-404. l G. Stormwater Pollution Prevention PI 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. ❑ 1. 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 Dustin Greene Address 172 South Pantops Drive City Charlottesville State VA Zip 22902 Daytime Phone(434) 979-8121 E-mail dgreene©dominioneng.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. . 1 FOR OFFICE USE ONLY r WPO#(D (�ig-- ( D J 4 �/ Fee Amount 3 ` Date Paid 1 I !mil j IBy who? Er etc, h1i2he,i(1 Receipt# 1 I aa- /0 Clc#d 21454 By. J r" < vi , Yic, ;43M90.l3 `� 7/1/14, Revised:7/10/14, 1/7/14 Page 2 of 2