HomeMy WebLinkAboutWPO201500063 Preconstruction Form 2015-12-02 � z
Request for Pre-construction Meeting and Grading Permit
from Albemarle County .► ~
Approved Plan Number: WPO- -0 l " 000(03
Approved Plan Name: V k Y-Qj l Ak a AyAOLF-f- &VIA C.L.
(Plans must be approved prior to a pre-construction meeting.)
Bond approved date: G-j 1 q/1 s
(Bonds must be approved and posted prior to a pre-construction meeting or permit.)
Responsible Land Disturber: � �
Print Name: C� `Q,n �i(�,:a l..�sJ — —
State Certification Number: `C 10 '^1 {)t /62_1% 1
Address (1 t O A l(ta St
City Ci art 0 �� CSO I t.e, __..VA Zip 2-State 6:a 3
Daytime Phone(Istb L(6I "" `'C 5G_E-mail_0 c h n s • • ft • ua t . (1 tyM
Primary Contractor:
Print Name U 1 i ► aAgekolf-r,g-erActs, �G
Address 4 Ct G k/t Y CKs t x-,e_ '• 1ZdC
City CrOieit"-- State V--A" Zip '2193',
Daytime Phone(t °1459"-5(103g-mail br\Jcxfl--h e,t fl sten
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
I and Jess than 5 $594.00
5 and less than 10 $74$_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 VSIVIP,VESCP fees were paid with the application.
711/14,Revised:8/29/14 Page 1 of 3
Name
Person(s)to attend the Pre-construction Meeting:
Names(type or print) Firm
p� Contact Number or email
.i,ail � 4' ' tip*�� c` l�i ' � '�: —'cow
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 Page 2 of 3