HomeMy WebLinkAboutWPO201900066 Application 2019-11-25 (2)-1pia. goqu
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name: Beaver Creek Medical Office Building
(The crane should be the same as it appears on pi,,cq
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 1tv the (ountt_jor nerr applications)
The following are required elements g1'ne11'applications [from code section 174011. Far:'evisions or
amendments, please indicate irhich items are being amended .Sigrratttres must he provided_ for anv
submission.
O A. Signature of the QLner 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, 1 hereby eertifv that all requirements of these plans and permits will be
complied with, and 1 have the authority to authorize the land disturbing activities and deveiopmerrt on the sill,
props[[). 1 hereby grans the C'atmt�' of.4lbernarle the right to enter 9pon the proper .v q required to ensure
compliance with she approved plans and permits.
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Tax Map & Parcel print Name of Owner u e of Owner Date
Tax Map & Parcel Print Name of Owner Si,nature of Owner Date
Tax %tap & Parcel Print Name of Owner .Signature of Owner Date
Tax Map & Parcel Print \mine of Owner Signature of Owner Dare
Contact Information for the Owners) to receive correspondence:
Print NameWest End Shops - West LLC
:address 2246 It Road, Suite 5
CitvChartottesville
StateVA Zip 22903
Daytime Phone l_ I F_o,oil
Revised 07/24:18 Page 1 of 2
0 B. All Fees [Code section 17-2081
For new or modified plans: Total acres proposed to be disturbed 1.51
acres un he I Total Fee Fee Due with this Fee with Transfer or
disturbed Application I modification of oormit
I I and less than 5 $2.700 $1.350 $i00
5 and less than I0 $3,40U $1,700 $250
10 and less than 50 $4.50U 47 'r,n
SO and less than $6.100 $3,050 $450
10U
100 and more 1 59.600 c t ann c,n
For (minor) amendments to an approved plan: $200 per review
Variances: $150
Mitigation Plan: $ I50
0 C. Registration Statement on the official DEQ form.
0 D. Erosion and Sediment Control Plan satisfying the requirements of code section 17402.
0 E. Stormwater Management Plan satisNing the requirements of code section 17-403.
OF. Pollution Prevention Plan satisfying the requirements of code section 17-404.
0 G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17405.
❑ 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 tas-buiits) for any existing facilities in the proposal satistyin, the
requirements of code section 17-422. `
Provide 2 conies ofall plans and anv supjNwalg documents. Professional seals must have original
signatures.
Additional lti/ormation if'nol provided on plans and documents:
Name of a Contact Person for con-espondence (usually the plan preparer, consultant or agent)
PrintNameJohn Thier (Turner Enterprises)
Address 250 West Main Street, Suite 201
CitvCharlottesville slateVA
zip 22902
Daytime Phone (434 ) 533-0788 E-mail lohnQtumer-enterprises.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 Hithout valid owner's
signatures will not be considered valid.
FOR OFFICE I SE ONLI I I wpoit �t - yt� l f
F.n Amount 5.�3SD.,Date paidl� �73�icho'!I/^,
_!�N�pl jRGjtT Receipta l l&Ck4— y Ry: J
Revised 0712418 Paac 2 of 2