HomeMy WebLinkAboutWPO202200004 Application 2022-03-04Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
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Project Name: Crozet Square and Oak Street (UPC 113188)
(The name should be the same as it appears on plans)
Is this an amendment to an approved plan? Yes ❑ No 91
Is this a revision or resubmission for review? Yes ❑ No FO
County File Number: (to be provided by the Countyfor 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 required to ensure
compliance with the approved plans and permits.
VDOT ROWS County of Albemarle 3/4/2022
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Tax Map & Parcel Print Name of Owner
Tax Map & Parcel Print Name of Owner
Tax Map & Parcel Print Name of Owner
Contact Information for the Owner(s) to receive correspondence:
Print Name
Address
City
Daytime Phone
Signature of Owner
Signature of Owner
Signature of Owner
Date
Date
Date
Revised 07/24/18 Page 1 of 2
® B. All Fees [Code section 17-208]
For new or modified plans; Total acres proposed to be disturbed 0.47
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
$700
For (minor) amendments to an approved plan, $200 per review
Variances, $150
Mitigation Plan, $150
❑ C. Registration Statement on the official DEQ form.
® D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402.
® E. Stormwater Management Plan satisfying the requirements of code section 17-403.
® F. Pollution Prevention Plan satisfying the requirements of code section 17-404.
® 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.
❑ I. 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 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)
Print Name Matt Harrell
Address 1700 Willow Lawn Drive, Suite 200
City Richmond
VA 7in 23230
Daytime Phone (6041 672-4717 E-mail matt.harrell@kimley-horn.com
*When applications and plans are reviewed, but not approved, and a response to comments is not received within 6 mouths
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 Amowt $ Date Paid
By who?
Receipt #
Ck# By:
Revised 07/24/18 Page 2 of