HomeMy WebLinkAboutWPO201900008 Application 2019-08-07 Virginia Stormwater Management Program (VSMP) 'l-,�
Application for Albemarle County
Project Name: 411ti) MI duct,
(The na ie should be the sante as ii appeals on plans)
Is this an amendment to an approved plan? Yes ❑ No ❑
Is this a revision or resubmission for review? Yes A No ❑
County File Number: \,NP DAD!CI (.7000 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 he provided for any
submission.
0 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 tans a p rtgjts.
CtZcwt�e ( 1(.4.)T
Tax Map&Parcel C Print Name of 0 i-Di Wei t f c - Signature of Owne 0-LE/pvier
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
XContact Information for the Owner(s)to receive correspondence: C411 i Tbe her
Print Name a Cm Tellorot 1 atn� Ct 4- , Ma-ce
Address Ill
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City � V\Y State Y A Zip Z'v}5 I 0
Daytime Phone 01 1l) l `0 1 tl O E-mail C o ce t 1. t,j"M
Revised 07/24/4 8 Page 1 of 2