HomeMy WebLinkAboutWPO202100016 Application 2021-03-12,u +r
Virginia Erosion and Sediment Control Program (VESCP)
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Application for Albemarle County
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(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 &
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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