HomeMy WebLinkAboutWPO202000056 Application 2020-12-09Virginia Stormwater Management Program (VSMP)�` ui
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Application for Albemarle County : r.
Project Name: Dawson Residence - T.M. 34-161
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No
Is this a revision or resubmission for review? Yes ® No ❑
County File Number: B2020-02305 (to be provided by the County for new applications)
The following are required elements of new applications [from code section 17-4411. For revisions or
amendments, please indicate which items are being amended. Signatures must be provided for any
submission.
® 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.
T.M. 34-161 David D. Dawson
Tax Map & Parcel Print Name of Owner
T.M. 34-161
A. Dawson
Tax Map & Parcel Print Name of Owner
Tax Map & Parcel Print Name of Owner
>L)
of Owner Date
V
gnature 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 David and/or Margaret Dawson
Address 676 Four Seasons Drive
City Ruckersville
VA ___ `_zip 22968
Daytime Phone -mail .
Revised 07/24/18 Page 1 of 2
® B. All Fees [Code section 17-208] $209 for Single Family
For new or modified plans; Total acres proposed to be disturbed i • 2 y 'Ac,S
Acres to be
Total Fee
Fee Due with this
Fee with Transfer or
disturbed
Application
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
$6,100
$3,050
$450
100
100 and more
$9,600
$4.800
$700
For (minor) amendments to an approved plan; $200 per review
Variances; $150
Mitigation Plan; $150
N/A C. Registration Statement on the official DEQ form.
® D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
® 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.
® H. 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 Qlans 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 Greg Gallagher
Address 1287-B Central Park Blvd
City Fredericksburg State VA Zip 22401
Daytime Phone (5401 850-8545 E-mail ggallagher@americashomeplace.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 S Date Paid By who? Receipt # Ck#
Revised 07/24/18 Page 2 of 2