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HomeMy WebLinkAboutWPO201500067 Application 2015-09-14 Nome Virginia Stormwater Management Program (VSMP) syr;, 'y Application for Albemarle County lupe .. ► Project Name: Wkf- -f�n 7kik, (The name should Erh the same as i/appears ecus on dans !p plans) Is this an amendment to an approved plan? Yes ❑ No)iff Is this a revision or resubmission for review? Yes O NoX County File Number: to be provided by the County for new applications) The following are required elements of new applications[from code section 17-401]. For revisions or amendments,please indicate which items are being amended. Signatures must be provided for any submission. 11A. Signature of the Property Owner 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,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. RO -3 Pi���,�r,E Ne,�� �©-t 4 �� �, 6-(z-,s Tax Map& Parcel Print Name of Property Owner Si. Owner Date 'lax Map& Parcel Print Name of Property Owner Signature of Owner Date 1 ax Map& Parcel Print Name of Property Owner Signature of Owner Date Tax Map& Parcel Print Name of Property Owner Signature of Owner Date Contact Information for the Owner(s)to receive correspondence. P;(7-LI Jet Libor kn,0 els 1_i' Address IfkS.n•Asek I-Elks RA 10 Daytime Phone( ) E-mail 7!1/14 Reviceri 7/1(1/14 1/7/14 Naar 1 nf2 tiotw A. All Fees [Code section 17-2081 For new or modified plans;Total acres proposed to he disturbed 11 . C.; A Acres to be Io'ai heti Fee Due with this Fee wt;h Trinislef or d disturbe -- - — .�rslrca[ion roodHcalror u' rerirtri Less than I ±$29r! $2,. ! and less than s -S5 rr,r} SI, f!!') ! g-00 5 and less than 1 t) 1 $3,400 $1 70C! $250 I0 and less that{50 $4,500 z5,l $•1511 $3.ii l 50 and less than !Cr? 1 $6;10()fi1f1.��i _-____...�_w_ mar , } 100 and e o;.,: $4,80 $$7t t. For(minor)amendments to an approved plan;$200 per review Var iann es• $150 er request) !ligation Plan;$150 ❑ C. Registration Statement on the official DEQ form. O D. Erosion and Sediment Control Plan satisfying the requirements of code section 17-402. ❑ E. Stormwater Management Plan satisfying the requirements of code section 17-403. O F. Pollution Prevention Plan satisfying the requirements of code section 17-404. O G. Stormwater Pollution Prevention Plan satisfying the requirements of code section 17-405. (H. Mitigation Plan satisfying the requirements of code section 17-406 for any proposed disturbance of stream buffers. O I. Requested Variations or Exceptions as provided in code sections 17-407 and 408. D J. Construction Record Drawings(as-builts)for any existing facilities in the proposal satisfying the requirements of code section 17-422. Provide 2 copies of all plans and any supporting documents. Professional seals must have original signatures. Additional information if not provided on plans and documents.' Name of a Contact Person for ccorrespondence(usually the plan preparer,consultant or agent) Print Name 1 rrt��t t ?tete) `ur i My:84 Y ��/-, on', .-. /) iim-t�f Address 1 7 G-- 5. fpato-ot25 Dr. tJ City C,14ar(uy1tk._. State Vit Zip 22-8 ii Daytime Phone t tj 11 e J et-Ism E-mail ii ,i ceQn41 _ *When applications and plans are reviewed,but not ao ' from the date of county comments,the application will be deemed withdrawn. Applications comments w without valid owner's not received within 6 months signatures will not be considered valid. UOR OFF ICL OSE n\'1.1' WPOq b 15.0.W At,.. �. 1 1 • ° t t�:W-10- w,1 f L�t -- `'- - ArY.� � i• U e.::�+.t� 1� 2 CJ co,1 I V 1 J� F:, _ 711114 Reviceri 7110114 117/14 Paan 2 of 7