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2. General Project Information:
4. Date
   Date
5. Project Title:
7. GPIN:
8. Ward Number:
10. Map of Wards
    Click here to check the map
11. Subdivision:
13. First Name
14. Last Name
16. Address1
18. Address2
20. City
21. State
22. Zip
24. Business Phone Number
25. Home Phone Number
27. Cellphone Phone Number
28. Email Address
30. Resource Protection Area (RPA) Information:
    Does the site contain any of the following (check all that apply)?

    1. Tidal Wetland
    2. Nontidal Wetland (connected by surface flow and contiguous to tidal wetlands or water bodies with perennial flow)
    3. Tidal Shores
    4. A vegetative buffer not less than 100 feet in width adjacent to and landward of the components listed above, and along both sides of any water body with perennial flow
32. If you are not sure, click below to go to Fredericksburg's GIS website
    FredGIS
34. Resource Management Area (RMA):
    Does the site contain any of the following (check all that apply)?

    1. Floodplains
    2. Highly erodible soils (including steep slopes)
    3. High permeable soils
    4. Nontidal Wetlands (not included in RPAs)
    5. Within 150-feet of a RPA vegetative buffer
36. If you are not sure, click below to go to Fredericksburg's GIS website
    FredGIS
38. Required Attachments:
    For individual residential lots:

    1. Submit a “to scale” plat depicting the location of all RPA features, 100-year flood plains, and wetland on the lot or parcel relative to all existing and proposed developments.
    2. Submit a signed copy, by a qualified professional, of a site-specific in-field evaluation and delineation for perennial flow based on the latest edition of guidance documents issued by the CBLAD
40. For site plans and subdivision plans:

    1. Submit “to scale” field-surveyed locations of all RPA features, 100-year flood plains and wetland on the site plan or subdivision plan.
    2. Submit a signed copy, by a qualified professional of a site-specific in-field evaluation and delineation for perennial flow based on the latest edition of guidance documents issued by the CBLAD
42. Plan of Development Information:
    Describe the proposed use and development:
44. Will there be land disturbance of any nature within a Chesapeake Bay Preservation Area?
    If yes, state the square footage and describe the location of disturbance:
46. For any proposed development or redevelopment within a Chesapeake Bay Preservation Area (CPBA) which disturbs any portion of the RPA, the elements of a Major Water Quality Impact Assessment (WQIA) shall be submitted along with this form in accordance with City of Fredericksburg Code Section 72-34.5L.(2). The elements of a Major Water Quality Impact Assessment may also be required at the Stormwater Administrator’s determination due to unique characteristics of the site or the intensity of the proposed use or development. Encroachment or modifications may require the submittal of a buffer mitigation plan in accordance with the latest edition of the Riparian Buffers Modification and Mitigation Guidance Manual from CBLAD.
48. 
    Will the proposed development require an encroachment or modification to the RPA buffer?
    If yes, describe the encroachment or modification being requested:
50. Will the proposed development require an exception request to either the Development Standards in the CBPO or Resource Protection Area Buffer Requirements for CBPAs (City Code Sections 72-34.5H. or 72-34.5I.)?
    If yes, state the specific Code subsection (s) from which the exception is requested and describe the nature of the request:
52. For all exception requests, an exception request application shall be submitted along with this form in accordance with City of Fredericksburg Code Section 72-34.5J.
    The applicable stormwater criteria for this project is either Section IIB (Runoff Reduction Method) or Section IIC (Chesapeake Bay Preservation Act requirements). Please check the appropriate Technical Criteria used for this project:
54. Section IIB:
    Is the project in Over 2500 SF and less than 1 acre?

    1. Yes
    2. No
55. Is the project greater than or equal to 1 acre?

    1. Yes
    2. No
57. If YES to either of the conditions above, runoff reduction and channel protection computations must be submitted with plans.
59. Section IIC:
    Will the proposed development result in greater than 16% impervious cover?

    1. Yes
    2. No
61. If yes, calculations and worksheets from the Virginia Stormwater Management Handbook for pollutant loading must be submitted with plans.
63. For all BMPs required, submit the required design drawings and calculations for the BMP, a plan sheet clearly showing the location of all BMPs and inspection and maintenance requirements for all BMPs.
    The property owner must complete, sign and have notarized a City of Fredericksburg BMP Maintenance Agreement and appropriate easements based on the specific BMPS required.
65. Please note that a construction record drawing, consistent with 9 VAC 25 870-55.D, will be required prior to release of project.
67. Applicant's Information:
69. Applicant's Name or Company:
71. Professional License Type:
72. VA License Number:
74. Address1
76. City
77. State
78. Zip
80. Email Address
81. Business Phone:
83. Home Phone:
84. Mobile Phone:
86. Applicant’s statement for Water Quality Impact Assessment:
88. I certify that I am a licensed professional in the Commonwealth of Virginia and that to the best of my knowledge, having completed a site-specific in-field evaluation and delineation of perennial flow, in my opinion the proposed development meets the requirements of the City of Fredericksburg Code, Section 72-34.5 Chesapeake Bay Preservation Overlay District.
90. Applicant's Signature:
91. Date:
    Date:
93. Applicant's Name (print or type):
95. Applicant’s statement for Wetlands:
97. I certify that I am a licensed professional in the Commonwealth of Virginia and that to the best of my knowledge, in my opinion the proposed development complies with the current requirements of section 404 of the Clean Water Act and state wetland regulations including the requirement that a wetlands delineation be performed and shown on the requisite plan.
99. Applicant's Signature:
100. Date:
     Date:
102. Applicant's Name (print or type):
104. Applicant’s statement for non RPA Disturbance/RMA Disturbance:
106. I certify that I am a licensed professional in the Commonwealth of Virginia and that to the best of my knowledge, in my opinion the proposed development will not result in land disturbance of any nature within a Resource Protection Area (RPA) or exceed two thousand five hundred (2,500) square feet within a Chesapeake Bay preservation Area (CBPA) and that there will be no concentrated flows into a CBPA from a disturbed area of more than two thousand five hundred (2,500) square feet to be located anywhere on the property.
108. Applicant's Signature:
109. Date:
     Date:
111. Applicant's Name (print or type):
Leave This Blank:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit

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