HomeMy WebLinkAboutWPO202200050 Application 2022-12-13DocuSign Envelope ID: 791F5140-8F50-4FA5-AC24-8E57FF114FOD
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County
Project Name: Forest Lakes Self Storage
(The name should be the same as it appears on plans)
Is this an amendment, modification, or transfer of an approved plan? Yes ❑ No
Is this a resubmission for review? Yes ❑ No ia
County File Number: WPO- (to be provided by the Counryfor new applications)
The following are required elements of new applications [§17-4011. For amendments and resubmission,
please indicate which items are being amended. Signatures must be provided for any submission.
52 A. Signature of the Owner for each parcel: (Required with every submission, 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.
Docu5i9netl by:
46-134-3 James Jessup 5apw's '�'SSVf 9/7/2022
Tax Map & Parcel Print Name of Owner Signatu e�WOWner 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: James Jessup
PO Box 9035
Address:
Charlottesville
City:
Daytime Phone:
VA _. 22906
250gto@pepsicva.com
Revised 07/l/21, 7/26/2021, 4/26/2022
DocuSign Envelope ID: 791F5140-8F50-4FA5-AC24-8E57FF114FOD
E313. All Fees [Code § 17-208]
For new or modified Dlans: Total acres oroDosed to be disturbed 3.os ac
Fee Due with this
Transfer or
Acres to be Disturbed
Application
Modification Fee
Total Fee = (Application Fee + 4% Technology Surcharge)
Single Family Dwelling only
$171.60
$23.92
Less than 1 acre
($165 + $6.60)
($23 + $0.92)
Single Family Dwelling only
$171.60
$236.08
1 and less than 5 acres
($165 + $6.60)
($227 + $9.08)
Less than 1 acre
$171.60
$20.80
($165 + $6.60)
($20 + $0.80)
1 and less than 5 acres
$1,591.20
$236.08
($1,530+$61.20)
($227+$9.08)
5 and less than 10 acres
$2,004.08
$294.32
($1,927+$77.08)
($283 + $11.32)
10 and less than 50 acres
$2,652.00
$353.60
$2,550+$102
$340+$13.60
50 and less than 100 acres
$3,596.32
$530.40
($3,458 + $138.32)
($510 + $20.40)
100 acres or more
$5,657.60
$824.72
($5,440 + $217.60)
($793 + $31.72)
❑ C. Amendments to an approved plan. Fee = $236.08 per review ($227 fee + $9.08 technology surcharge)
❑ D. Registration Statement on the official DEQ form.
❑ E. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
❑ F. Stormwater Management Plan satisfying the requirements of Code § 17-403.
❑ G. Pollution Prevention Plan satisfying the requirements of Code § 17-404.
❑ H. Stormwater Pollution Prevention Plan satisfying the requirements of Code § 17-405.
Ill. Mitigation Plan satisfying the requirements of Code § 17-406 for any proposed disturbance of
stream buffers. $176.80 ($170 fee + $6.80 technology surcharge)
❑ J. Requested Variations or Exceptions as provided in Code §17-407 and §17-408. $176.80 ($170 fee +$6.80
technology surcharge)
Provide 2 copies ofall plans and any supporting documents or submit all documents online. 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):
Name (Print): Jason
Address: PO Box 10588
City: Greenville
SC 7in 29603
Daytime Phone: ( ) 864-918-1190 E-mail: jasont@capllc.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 without valid owner's
signatures will not be considered valid. Active permits are subject to annual maintenance fees 1§ 17-2081.
FOR OFFICE USE ONLY
WPO #
Fee Amount $ Date Paid
By who?
Receipt
Revisoa 07n01� =62021; 446n02:2