HomeMy WebLinkAboutWPO201500035 Preconstruction Form 2015-09-10 New
Request for Pre-construction Meeting and Grading Permit
from Albemarle County +tFAG !
Approved Plan Number: WPO- Zn/s ` 0 0 o3.S�
Approved Plan Name: )ok-14. frr-/c ,/v*Ny4, 4,11,4/ L4/4� 111°`;41 i e s/�
(Plans must be approved prior to a pre-construction meeting.)
Bond approved date:
(Bonds must be approved and posted prior to a pre-construction meeting or permit.)
Responsible Land Disturber:
Print
//
Print Name: {!t-yh/.f 1��‘ti J , . 6f /je,J CAp;ceH71erpoJeJ, .c.)
State Certification Number: f 1.7'91)
Address JO Zfl i';-)d�., �1-k
City � h�jo ✓i /it J V4 State v// Zip 72 yd Z
Daytime Phone(434 ) (:)2^3-0 E-mail c 4 vv 4, -F6 /y Cov"i
ta°
Primary Contractor: --��'
Print Name lit((ley ev J C Au; C C �N � �1 J�� :•�L c •
Address /0 1 0 L��,Je �ve h u c
City C it.w/ '1,01 Vi./1tc 1/I State V/111 Zip 7-2 7°
d /
Daytime Phone(f34 ) Z g 1 "0 d E-mail elv w t cc_C � iJ (,Co►i
Permit Issuance and First Year Maintenance Fees: (Request must include payment)
Total acres proposed to be disturbed is contained on the approved plan and application:
VSMP:
Acres to be disturbed Fee Due at Grading Permit
Less than 1 $63.80
1 and less than 5 $594.00
5 and less than 10 $748.00
10 and less than 50 $990.00
50 and less than 100 $1,342.00
100 and more $2,112.00
For plans exempt from VSMP,VESCP fees were paid with the application.
7/1/14,Revised: 8/29/14 Page 1 of3
f
*ow -IMP 3 - A *is
Person(s)to attend the Pre-construction Meeting:
Names(type or print) Firm Contact Number or email
1t-61 €4 / ,z/i5 fie- 434 9e( 099c5
6,47 co,ttL7f(-07-fo
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?
• •
c,re: LA iv,
• ;°;: , \
7/1/14,Revised:8/29/14 Page 2 of 3