HomeMy WebLinkAboutWPO202000039 Application 2021-05-04Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name: Crozet Elementary School Addition, Renovation and Site Improvements
(The name should be the same as it appears on plants)
Is this an amendment to an approved plan? Yes ® No ❑
Is this a revision or resubmission for review? Yes ❑ No l$
County File Number: WP02020-00039
(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.
IM 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, 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 upon the pro s required to ensure
compliance with the approved plans and permits.
05600-00-00-064EO County of Albemarle School Board 5,
Tax Map & Parcel Print Name of Property Owner ture nP rlarnrr
Tax Map & Parcel Print Name of Property Owner Signature of Owner 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 Albemarle County School Board Contact: Joseph Letteri
Address 401 McIntire Road
City Charlottesville
state VA Zip 22902
Daytime Phone (434) 975-9340 E-mail jietteri@kl2albemarle.org
7/1/14, Revised: 7,110/14, 1/7/14 Page 1 of
DO B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 6.60
be
n 1
this
Fee with Transfer or
modification of ermit
$20
s than 5
$200
M$4,800$700
s than 10
RMOTC
VJ$9,600
$250
ess than 50
$300
ess than 100
$450
more$700
For (minor) amendments to an approved plan; $200 perreview
Variances; $150 (per request)
Mitigation Plan; $150
X C. Registration Statement on the official DEQ form.
N D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
CK E. Stormwater Management Plan satisfying the requirements of code section 17-403.
CK F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
9 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.
❑ 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 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 Name Bryan Cichocki, PE
Address 608 Preston Ave, Suite 200
City Charlottesville State VA Zip 22903
Daytime Phone (A�1) 327-1688 E-mail craig.kotarski@timmons.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 $ Date Paid By whop _ Receipt # Ck# By:
711/14, Revised: 7/10/14, 1/7/14 Page 2 of 2