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APPLICATION TO BUILDING INSPECTIONS AND ZONING DEPARTMENT GREENE (County of Greene)

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BROWSE COUNTY OF GREENE (VA) FORMS

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APPLICATION TO BUILDING INSPECTIONS AND ZONING DEPARTMENT
GREENE COUNTY, VIRGINIA
434-985-5204 (BLDG) 434-985-5282 (ZONING) 434-985-1459 (FAX)
P.O. BOX 358, STANARDSVILLE, VA 22973 www.gcva.us
PERMIT NUMBER: _____________ PERMIT TYPE: __________
Page 1 of 2
2. Property Information: Water Source: Public  Well Sewer Source: Public Sewer  Private Septic
State Route Number:
*Street Address:
Subdivision Name:
Lot Number:
Acreage: Tax Map Parcel #:
Estimated Date of Purchase:
3. Improvement Information:
Type of Improvement
Description/Explanation:
□New Residence □ New Commercial
□Addition /Deck/Porch □ Alter Commercial
□Remodel □ Other (Explain)
□Garage □ Electrical Only
□Shed □ Plumbing Only
□Barn/Farm Use □ Mechanical Only
□Mobile Home (serial #) □ Signs Installation
□Pool □ Duplex/Apartments # Units
Estimated Value of Project:
Is owner acting as contractor?
4. New Residence/New Remodel Information: Addition/Remodel Usage:
Size:
Total Finished Sq. Ft.:
Unfinished Sq. Ft.:
Foundation Type:
Type of Siding:
Type of Heat:
Fire Place Type:
# of Bedrooms:
# Bathrooms:
Basement: Finished/ Unfinished
Sq Ft. Basement: _____
Unfin Basement ____ SF
Attached Garage Size:
Front Porch Size:
Rear Deck Size:
5. New Proposed Garage/Shed/Deck/Other Information:
Size:
Attached/Detached:
Amp of Electric Service
Siding Type:
Sq. Ft.:
# of Stories:
Will Plumbing Be Installed:
Value of Project:
6. Contractor Information: Address Phone # State License Number/Class Expiration Date
Building Contractor Name:
Electrical Contractor Name:
Plumbing Contractor Name:
Mechanical Contractor Name:
All contractors are required to have a County Business license. For more information call 985-5211.
7. Mechanics Lien Information:
MLA Company Name:
Address/Phone/Fax
*New Street Address: ___________________________________________________________________
(This will be assigned during the permit approval process)
1. Applicant:
Current Property
Owner:
Mailing Address
Do you want your permit
< mailed to this address?
Phone Number:
Cell Phone: Fax Number:
Email Address:
Circle the best phone number for point of contact
APPLICATION TO BUILDING INSPECTIONS AND ZONING DEPARTMENT
GREENE COUNTY, VIRGINIA
434-985-5204 (BLDG) 434-985-5282 (ZONING) 434-985-1459 (FAX)
P.O. BOX 358, STANARDSVILLE, VA 22973 www.gcva.us
PERMIT NUMBER: _____________ PERMIT TYPE: __________
Page 2 of 2
Affidavit for Virginia Contractor’s Licensing Law – Please Read
I affirm that I am the owner/agent of a certain tract above located in Greene County and that I have applied for a permit
to erect a structure on said land and/or repair/improve structure on said land. I certify that I have the
consensus/approval of all property owners to apply for this permit.
I affirm that I am aware of provisions of Title 54.1 Chapter 11, Code of Virginia that requires a contractor to be
properly licensed before he may bid or undertake contracting work of $1,000 or more. I further certify that I am
familiar with the responsibilities of a awarding authority specified in Section 54.1111 of the Code which prohibits any
awarding authority from issuing permits or allowing the issuance of such permits to any contractor not properly
licensed under the provisions of the Code, and that to do so would constitute the commission of a misdemeanor.
This permit becomes null and void if work or construction authorized is not commenced within 6 months, or if
construction or work is suspended or abandoned for a period of 6 months at any time after work is commenced.
It is my responsibility to insure adherence to all zoning, building and erosion/sediment control regulations applicable in
this jurisdiction. I understand that state law prohibits illegal contracting. All contractors need a state and county
license.
Signature of Owner/Authorized Agent ___________________________ Date: _________
Print Name: __________________________________________________________
BELOW FOR OFFICE USE ONLY: Tax Map Parcel Number: ____________
Zoning Approval:
Zoning Type:
Zoning Notes:
E&S Review
Zoning Adm. Signature:
Date:
Approval Date:
Building Official Approval
Building Official Signature:
Notes:
Approval Date:
Plan File Number: Code Reviewed Under:
Commercial Occupant Load:
Construction Type: Use Group:
Charges/Payment Account # for Treas. NOTES:
Access. Use/Other
$
Building
$
Basement-Unfinish
$
Electrical
$
Plumbing
$
Mechanical
$
Subtotal
$
3-100-013030-0008
2.0% State
$
3-100-013030-0033
Zoning Review
$
3-100-013030-0006
Assign Address
$
3-100-013030-0006
Septic Review Fee
$
3-100-013030-0018
Erosion Fee
$
3-100-013030-0032
SWM Fee
$
3-100-013030-0035
Proffer Payment
$
3-100-013030-0019
TOTAL DUE
DATE PD
RECEIPT #
CHECK
CASH
STAFF
PAYEE NAME
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signature
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AGREEMENT IN LIEU OF AN EROSION AND SEDIMENT CONTROL PLAN
FOR SINGLE FAMILY RESIDENCES/ACCESSORY STRUCTURES
PERMIT #: _______________
In lieu of submitting a formal erosion and sediment control plan for the construction of a single family
residence and/or accessory structure, I agree to comply with the requirements of the Virginia Erosion and
Sediment Control Handbook, latest edition, and install erosion control measures in accordance with the
Handbook standards & specifications in order to protect against the transport of soil and sediment off of
the property. I further agree to comply with any additional requirements deemed necessary by Greene
County erosion control inspectors. Such requirements shall be based on established conservation
standards and shall represent the minimum practices necessary to provide adequate control of erosion
and sedimentation on or resulting from this construction. Erosion controls required shall be installed as a
first step in the construction process and include at a minimum:
1. A stone construction entrance shall be provided wherever traffic will be leaving a construction site and
transporting mud directly onto a public or private road or other paved area. Any mud transported off of the
site will be cleaned up promptly.
2. Silt fence or other protective measures shall be provided wherever sediment from disturbed areas may leave
the site. Such protective measures must be provided before significant land disturbing activities may
proceed.
3. All denuded areas shall be stabilized within seven (7) days of final grading with permanent vegetation or a
protective ground cover suitable for the time of year. Temporary soil stabilization shall be applied to
denuded areas that may not be at final grade but will remain undisturbed for longer than fourteen (14) days.
4. All culvert pipes including driveway pipes shall have proper inlet and outlet protection.
I understand that failure to comply with this agreement may result in civil and/or criminal penalties and
may require the submission and approval of a formal erosion control plan with an appropriate
performance guarantee bond (adequate for the total cost of grading, drainage and erosion & sediment
control, plus 25% for administrative expenses). I further understand that a formal erosion control plan or
performance guarantee may be required either prior to issuance of a Building Permit or at any time prior
to an approved final inspection, at the sole discretion of Greene County.
I hereby grant the County of Greene the right to enter upon this lot periodically to assure compliance,
including performing remedial work if the Owner/Agent fails to comply with directives by the County. I
further agree to pay for all costs for such remedial work within fourteen (14) days after receipt of invoices
received for such work.
___________________________________________ _________________
Signature of Property Owner/Authorized Agent Date
_______________________________________________________
Mailing Address and Phone Number
____________________________________________________________________________________________________________________
Approved By: _____________________________ Date: ______________
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signature
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AGREEMENT IN LIEU OF A STORMWATER MANAGEMENT PLAN
FOR SINGLE FAMILY RESIDENCES/ACCESSORY STRUCTURES
PERMIT #: _______________
In lieu of submitting a stormwater management plan for the construction of a single family residence
and/or accessory structure, I agree to comply with the requirements outlined in this Agreement and as
determined necessary by the County of Greene Program Administrator. Such requirements shall represent
the minimum practices necessary to ensure compliance with Chapter 38, Article 4 of the Code of The
County of Greene, VA for construction of a single family residence and, or accessory structures on a single
family residential lot.
As a minimum, I agree to:
A. As required by the Construction General Permit (VAR10), keep a signed copy of this
Agreement In Lieu of a Stormwater Management Plan in my Stormwater Pollution
Prevention Plan (SWPPP).
B. Minimize to the maximum extent possible post-construction runoff, and to prevent
flooding or erosion on adjacent downstream properties.
C. Discharge runoff from all impervious surfaces including: roof surfaces, paved areas,
etc. to lawn or wooded areas on the lot, and to daylight any downspout extension, or
other stormwater pipe at least 10’ from the property line, unless granted an exception
by the Program Administrator.
D. Prevent concentrated points of runoff from leaving the property.
I understand that failure to comply with this agreement and any resultant inspection report noting non-
compliance items will result in the county issuing a Notice To Comply for non-compliance of the County of
Greene, VA Stormwater Management Ordinance and may require that the applicant post a Performance
Guarantee/Bond for lot stabilization and any erosion and sediment control measures that may be needed.
I also understand that the County of Greene may at any time require me to submit a Stormwater
Management Plan in accordance with 9VAC25-870-55 of the VSMP Regulations.I further understand that
failure to correct said items by the deadline indicated will result in issuance of a Stop Work Order for ALL
construction activities, and may also result in permit revocation and, or enforcement through civil
proceedings.
___________________________________________ _________________
Signature of Property Owner/Authorized Agent Date
_______________________________________________________
Mailing Address and Phone Number
____________________________________________________________________________________________________________________
Approved By: _____________________________ Date: ______________
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signature
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LAND DISTURBANCE PERMIT APPLICATION
SINGLE FAMILY RESIDENCE/ACCESSORY STRUCTURE
PERMIT #: _______________________
Property Owner Name: _______________________________________________________
Mailing Address: ____________________________________________________________
E-mail & Phone #: ___________________________________________________________
Applicant/Agent Name (If different from Owner) ___________________________________
Mailing Address: ____________________________________________________________
E-mail & Phone #: ___________________________________________________________
Project Address/Location: _____________________________________________________
Project Tax Map #: __________________________________________________________
Responsible Land Disturber (If different from Owner): ______________________________
Responsible Land Disturber Certification # and Expiration: ___________________________
INSTRUCTIONS:
Completion of this application is required to obtain a permit to construct a single family residence in the County of
Greene, VA. All projects require a “Site Evaluation” form. Projects disturbing greater than 5 acres require a
meeting with the Program Administrator prior to permit application. Projects with disturbance less than 5 acres will
submit an “Agreement In Lieu of an Erosion and Sediment Control Plan”, and an “Agreement In Lieu of a
Stormwater Management Plan” (when required). For applicants required to obtain VSMP Permit coverage, a
Stormwater Pollution Prevention Plan (“SWPPP”) handout will be provided by the county and is the applicant’s
responsibility to update as needed, and be made available to the County upon request. Instructions for the “SWPPP”
accompany the handout.
PERMANENT STORMWATER BMPs:
Permanent stormwater Best Management Practices (BMPs) installed for treatment of quality and quantity of runoff
shall be set forth in a document, or enforceable mechanism that identifies the BMP(s) and provides an operation and
maintenance schedule, and shall run with the land. Applicant shall list BMP(s) to be installed/used on the
“Agreement In Lieu of a Stormwater Management Plan”. The Program Administrator shall determine the type of
document/mechanism to be used during application review, and require applicant to complete the required document
before permit issuance. Conditions of said agreement shall conform with Section 38-131 of the County of Greene
Stormwater Management Ordinance. Said agreements requiring recordation shall be done so prior to permit
issuance.
PERFORMANCE GUARANTEE:
Failure to comply with the conditions of either the “Agreement In Lieu of an Erosion and Sediment Control Plan”,
or the “Agreement In Lieu of a Stormwater Management Plan” that result in issuance of a Notice To Comply, or
Stop Work Order shall require the applicant to post a Performance Guarantee for lot stabilization and any measures
required to bring the site into compliance. Guarantees are $1,000.00/quarter-acre of disturbed area. No Final
Inspections will be performed until the guarantee has been posted and all required corrections have been made to
achieve compliance. If any portion of the guarantee is used by the County of Greene for corrective measures, the
bond must be replenished by the applicant until the Program Administrator determines that the lot has achieved
mature stabilization sufficient to inhibit erosion, and the bond released.
PERMIT FEE AND APPLICATION REQUIREMENTS:
Before a permit will be issued for single family residential construction projects, applicants must pay the required
application/permit fees. Fees and application requirements are based on amount of acreage disturbed, and on
whether or not the subject parcel is part of a common plan of development.
Note: accessory structures are not exempt, and must obtain a permit when disturbance exceeds 10,000
square feet. Included are: sheds, garages, barns, and other structures that require land disturbing activities.
Note: disturbances greater than 5 acres require a Pre-Application meeting with the Administrator.
Disturbed Acreage (Includes footing excavation, driveway, drain field, yard, etc.): _____________
Parcel was created as an individual lot either by plat, or deed prior to July 1, 2004 (YES) (NO):
Date Created: _____________
A. Parcels created before July 1, 2004 either by plat, or deed that disturb less than 1 acre are NOT
required to obtain VSMP Permit coverage:
Land Disturbance Application for Single Family Residence
Agreement In Lieu of an Erosion and Sediment Control Plan
Site Evaluation Form
Required Fees:
E&SC Fee…………………………. $150
B. Parcels created prior to July 1, 2004 either by plat, or deed that disturb between 1 and 5 acres, and
ALL parcels created on, or after July 1, 2004 regardless of amount of disturbance ARE required
to obtain VSMP Permit coverage:
Land Disturbance Permit Application for Single Family Residence
Agreement In Lieu of an Erosion and Sediment Control Plan
Agreement In Lieu of a Stormwater Management Plan
Site Evaluation Form
SWPPP (Contractor/Applicant keeps on site)
Required Fees:
E&SC Fee………………………….$150
Greene County VSMP Fee………. $209
TOTAL FEE DUE = _________
Signature of this application by the owner/applicant certifies that all requirements of the County of Greene
Erosion and Sediment Control, and Stormwater Management ordinances will be complied with, and that all
elements of the approved plan, or Agreement In Lieu of a Plan(s) shall be followed unless a variance is
granted by the County of Greene Erosion and Sediment Control Administrator.
_______________________________________________________ __________________________
Signature of Owner/applicant Date
___________________________________________________________________________________________
Date Application Received ___________________ Fee Received Date _____________________
Lot Stabilization Bond/Escrow ________________ Received By __________________________
Bond/Escrow _______________________________ Receipt # _____________________________
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SINGLE FAMILY APPLICATION CHECK LIST
Complete Application: All areas of the application need to be completed. If printed off the internet,
make three copies of the application once you have completed it.
Contractor’s Information: A copy of contractor’s state license must be submitted.
A copy of all subcontractors state license must be submitted with application.
A copy of contractor’s Greene County business license. Call the Commissioner
at (434)985-5211 if you have questions.
Building Plans: Two sets of plans showing structural components room layout, window sizes, location of
smoke detectors. We prefer 11x 14 or smaller size plans for residential permits.
Site Sketch: Site sketches must be drawn on a copy of a survey plat. Current surveys are located in
Clerk’s Office. Show all buildings located on property, show location of proposed
buildings and the distance to the property lines of new construction. The distance
should be shown to the front, sides and rear property lines. New driveway location must
be drawn and neighboring driveways should be shown with the house numbers. Two
copies of the sketch must be submitted. Zoning inspections will be done in review
process therefore all property lines and corners must be clearly marked upon submittal.
VDOT: Proof of an entrance permit must be submitted if your driveway is located on a state
maintained road or a future proposed state maintained road. You can call 434-293-0011
to obtain information about this requirement. Existing driveway must be reviewed by
VDOT also.
Private Septic: You must apply to the Health Department for these permits. A copy of the approved
Private Well: permit must be submitted with the building permit application. Contact the Health
Department at 434-985-2262.
Public Water
Public Sewer: Water/Sewer services located east of Stanardsville must be purchased thru the County
Administration Office (434-985-5201). The tax map number must be given at the time of
purchase. Verification of this purchase must be submitted with the permit application.
You will also need to obtain a letter from Rapidan Service Authority (434-985-7811)
stating that they will provide these services to the lot. This letter needs to be submitted
with your permit application no matter where your property is located if it is served by
RSA public water/sewer.
T&L Water: This private water company (434-985-7504) provides water to the Twin Lakes and
Greene Mtn. Lake areas. You must submit a letter from T&L Water Company stating
they will provide water to your lot if you are in their service area.
Erosion and
Sediment Control: ALL Completed of the Land Disturbance Permit Application forms must be submitted
with application for building permit. You can contact the Erosion and Sediment Control
Administrator by calling 434-985-5206.
There may be additional forms to complete in our office upon arrival.
Your application will NOT be accepted for review if the above requirements are not submitted with the
application packet. Payment is due at the time of submittal by check or cash.
SITE EVALUATION FORM FOR SINGLE FAMILY HOMES
To be completed by all Single Family Home Building Permit Applications. Circle the response
that best represents the project site.
1. Distance to a Watercourse:
a. <50 feet
b. 50 feet to 150 feet
c. >150 feet
2. Crossing Water Course (Stream)
a. Yes-Every 2 weeks
b. No
3. Buffer Width Surrounding land disturbance
a. 0-50 feet
b. 50-150 feet
c. >150 feet
4. Buffer Condition
a. Very good (dense grass, hay field)
b. Good (average grass, forest, pasture)
c. Fair (poor grass, fair pasture)
d. Poor (bare soil, pavement)
5. Distance from disturbance to downstream adjacent property
a. <50 feet
b. 50 feet to 150 feet
c. Greater than 150 feet
6. Does the overall slope of the disturbed area meet any of the following criteria:
a. 0-7% and greater than 300 feet long
b. 7-15% and greater than 150 feet long
c. Greater than 15% and greater than 75 feet long
d. None of the above
7. Approximate Disturbed Acreage
a. <1/2 acre
b. ½ - 1 acres
c. 1-2 acres
d. Greater than 2 acres-Every 2 weeks
8. Driveway Length
a.
b. -
c.
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APPLICATION TO BUILDING INSPECTIONS AND ZONING DEPARTMENT GREENE (County of Greene)

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Completed 19 July 2020

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