HomeMy WebLinkAboutWPO202200038 Application 2022-12-13DocuSign Envelope ID: F266DCE3-5846452C-84454896455143B6
Virginia Stormwater Management Program (VSMP)
Application for Albemarle County it
Project Name: Breezy Hi 11
(The name should be the same as it appears on plans)
Is this an amendment, modification, or transfer of an approved plan? Yes ❑ No CC
Is this a resubmission for review? Yes ® No ❑
County File Number: WPO- 202200038 (to be provided by the Countyfor new applications)
The following are required elements of new applications [§17-401]. For amendments and resubmission,
please indicate which items are being amended. Signatures must be provided.for anysubmission.
a 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.
WAS & 48A
—O uSlgmd by:
fyic s6k, manager 12-12-2022
—157Fi®iRr;oam.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
Tax Map & Parcel Print Name of Owner Signature of Owner Date
Contact Information for the Owner(s) to receive correspondence:
c/o Southern Development - Charlie Armstrong
Address: 142 South Pantops Drive
City: Charlottesville State: Virginia Zip: 22911
Daytime Phone: (434)245-0894 E-mail: CharlesAlFi-southcm-develooment_com
Revised 07/1/21; 7/26/2021
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E B. All Fees [Code § 17-208]
For new or modified plans: Total acres proposed to be disturbed 50.0 Acres
Fee Due with this Transfer or
Acres to be Disturbed
Application Modification Fee
Total Fee = (Application Fee +40'. Technology Surcharge)
Single Family Dwelling only
$171.60
$23.92
Less than 1 acre
($165+$6.60)
(S23+$0.92)
Single Family Dwelling only
$171.60
$236.08
1 and less than 5 acres
($165+S6.60)
(S227+S9.08)
Less than 1 acre
$171.60
$20.80
($165+S6.60)
(S20+S0.80)
1 and less than 5 acres
$1,591.20
$236.08
(S1,530 + $61.20)
(S227+S9.08)
5 and less than 10 acres
$2,004.08
$294.32
(S1,927+S77.08)
(S283+S 11.32)
10 and less than 50 acres
$2,652.00
$353.60
($2,550+$102)
($340+S13.60)
50 and less than 100 acres
$3,596.32
$530.40
(S3,458+$138.32)
(S510+S20.40)
100 acres or more
$5,657.60
$824.72
(S5,440+S217.60)
($793 + S31.72)
❑ C. Registration Statement on the official DEQ form.
IN D. Erosion and Sediment Control Plan satisfying the requirements of Code § 17-402.
® E. Storinwater Management Plan satisfying the requirements of Code § 17-403.
El F. Pollution Prevention Plan satisfying the requirements of Code § 17-404.
11 G. Stormwater Pollution Prevention Plan satisfying the requirements of Code § 17-405.
❑ H. Mitigation Plan satisfying the requirements of Code § 17-406 for any proposed disturbance of
stream buffers. $176.80 (S170 fee + S6.80 technology surcharge)
❑ T. Requested Variations or Exceptions as provided in Code § 17-407 and § 17-408. $176.80 (S170 fee +
$6.80 technology surcharge)
Provide 2 conies of all plums and any supporting documents or submit all documents online.
Professional seals mart have original signatures.
Additional information if not provided on plans and documents:
Name of a Contact Person for correspondence (usually the plan prepater, consultant, or agent):
Name (Print):
Address: 999 Second Street. SE
City: Charlottesville State: Virginia Zip: 22902
Daytime Phone: (434)977-0205 E-mail: cmulliganLikoudabush.com
s 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.