HomeMy WebLinkAboutWPO202100039 Application 2021-07-08Virginia Stormwater Management Program (VSMP) t
Application for Albemarle County
Project Name: Mountain View Elementary
(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:
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.
❑ 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 rcqd to ensure
compliance with the approved plans and permits. 1
Map & Parcel Print Name of Owner
571
Date
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print 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 S I 0 1?;F tw-1
Add
City
Daytime Phone _�� �[ �j1 �� g_1I ()
•21
Revised 07/24/18 Page I oft
❑ B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed
Acres to be
disturbed
Total Fee
Fee Due with this
Application
Fee with Transfer or
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
100
$6,100
$3,050
$450
100 and more
$9,600
$4,800
1 $700
For (minor) amendments to an approved plan; $200 per review
Variances; $150
Mitigation Plan; $150
\Nkl C. Registration Statement on the official DEQ form. /-- ( aC
D. Erosion and Sediment Control Plan satisfying the requirements of code section 17402.
E. Stormwater Management Plan satisfying the requirements of code section 17-403.
\1tl. F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
W G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405.
%Nft. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of
stream buffers.
Requested Variations or Exceptions as provided in code sections 17-407 and 408.
Xd'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)
City OAD, state VPt Zip 07,
Daytime Phone (lJ l E-mail d L U'(.i' 04 11K - . cmy-A
*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 N CkN By:
Revised 07/24/18 Page 2 of 2