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HomeMy WebLinkAboutWPO202100016 Application 2021-03-12,u +r Virginia Erosion and Sediment Control Program (VESCP) .Jf dye Application for Albemarle County �;' a r` �rMa)117` (This application is only to be used for projects exempt from the Virginia Stormwater Management Program, VSMP, and the DEQ General Permit) Project Name: Kappa Sigma International Headquarters Maintenance Plan (The name should be the some as it appears on plans) Is this an amendment to an approved plan? Yes ❑ No NO Is this a revision or resubmission for review? Yes ❑ No 0 County File Number: (to be provided by the County for 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. ® 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 1 have the authority to authorize the land disturbing activities and development on the subject property. 1 hereby grant the County of Albemarle the right to enter upon the property as required to ensure compliance with the approved plans and permits. 91-16D Tax Map & Parcel Tax Map & Parcel Tax Map & �r Print Name of Owner Print Name of Owner Signature of Owner Date 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 P � A (t GQbria�d Address �C� \Q S(J6-W- 1w C( City— C Up ile $)t / State % — ZipZZg62- Daytime Phone (LM E-mail 7/1114. Revised: 7/10114. 1/7/15. 10/17/IR Pane 1 of 9 B. All Fees [Code section 17-207] Total acres proposed to be disturbed 0.56 ac Acres to be disturbed Total Fee Less than I $150 per review More than 1 $300 per review For amendments to an approved plan; $200 per review Variances; $150 (per request) Exceptions; $240 Mitigation Plan; $150 Construction Record Drawing; $300 17 C. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ D. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. ❑ E. Requested Variations or Exceptions as provided in code sections 17-407 and 408. ❑ F. Construction Record Drawings (as-builts) for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies ofall 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 Address 999 Second St. SE, Suite 201 City Charlottesville Daytime Phone 4( 34 ) 987-2836 E-mail skirby@roudabush.com State Va Zip 22902 *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 p Fee Amount $ Date Paid By who? Receipt # CkH By: 7/1/14.Revised:7/10/14.1/7/1.5.10/17/1R Page 2of2