HomeMy WebLinkAboutWPO201600008 Preconstruction Form WPO VSMP 2016-11-28 C511-1 Zk ' ib
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Request for Pre-construction Meeting and Grading Permit '
from Albemarle County
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Approved Plan Number: WPO- 201 " V 0 00%
Approved Plan Name: t y&ort, 2C -1 ` ?h45L
(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 Name: W��I I4Yh 7, 'oed w►cr
State Certification Number: 161:43
Address ql k pi +OWb L'a II
City ButiAp.,05 State VA Zip 250 2L1
Daytime Phone(910) 112_ 5105 E-mail r01MAH 4.044/4 4'7 11 C�i�� et l 1, OM
Primary Contractor: (/ (�
Print Name pmi,
Address 214g �taa.s�tw�rH R sa
City 90 IM<DRS S State Vit Zip 14°141
Daytime Phone 514 0) 51 °C E-mail apo juvat<..e,XC4vA IA t� i ra,.(•C�
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
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Person(s)to attend the Pre-construction Meeting:
Names(type or print) Firm Contact Number or email
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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