HomeMy WebLinkAboutWPO202200016 Preconstruction Form 2022-05-17Request for Pre -construction Meeting and Grading Permit
from Albemarle County — VSMP
it
Approved Plan Number: WPO- 202200016 DEQ Permit # (if applicable): VAR 10- N/A
Approved Plan Name: 2628 Penny Lane TMP 89-53C
(Plans must be approved prior to a pre -construction meeting.)
Bond approved date: Waived (FVP)
(Bonds must be approved and posted prior to a pre -construction meeting or permit.)
Responsible Land Disturber:
Print Name: 16��5 \�=
State RLD Number: \ (o ZZ G\
Address: `1't' C�, 1�1\ S rh o 2\ 4_� V\ A l
City: E,5 v-3 \ State: Zip: -7z 4�(
Daytime Phone: (As • 53 \ - 13 E-mail: / C5 CV\, Y
Primary Contractor:
Print Name: C— � 1-0 \ 'Y \ ofCSG (_C
Address:
5 i -t(. z q r�,—t
City: State: 'mil ice` Zip: b
us
Daytime Phone: (41�) �- E-mail: 6z1_So% Q-,"L\\ \*s pg
QA)L/�3/}�Z�tr-�J loZ C-fa \- Ii -- {U� 0
Permit Issuance Fees (Request must include payment) [Code §17-708]:
Total acres proposed to be disturbed as shown on the approved plan and application: k Acres
Total Fee Due for Grading Permit
Acres to be Disturbed
Total Fee (Application Fee +4%Technology surcharge)
Less than 1
$74.88
$72+$2.88
aml y Dwelling only —
$74.88
($72 + $2.8
1 and less than 5 acres
$700.96
$674 + $26.96
5 and less than 10 acres
$881.92
($848 + $33.92)
10 and less than 50 acres
$1,167.92
$1,123 + $44.92
50 and less than 100 acres
$1,581.84
($1,521 + $60.84
100 acres and more
$2,490.80
$2 395 + $95.80
Annual maintenance fees are assessed in arrears on April 1 each year or portion of a year that this permit is active
[Code § 17-208].
711/14, Revised: 8/29/14, 10/18/18, 7/I/2021, 7/26/2021, 9/15/2021 Page 1 of
Person(s) attending the Pre -construction Meeting:
Names (Type or print) Finn Contact Number or email
D S 5 C..,c;�' (� l i.1.. C t_• �`�'(L\.L� <'sS �SS"i;4..+.i'..Cl<3N t_✓t3�� 5 � \ —'I 3 l �'\
c:V T CL\ LI.0 dc�0� la-�s: Mo.11r .CttY\
The second part of the application fee is required to be paid with this request. This fee amount is:
FOR OFFICE USE ONLY Permit Issued Date
By who?
7/1/14, Revised: 8/29/14, 10/18/18, 7/1/2021, 7/26/2021, 9/15/2021 Page 2 of3