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City of Lynchburg

sdcandm@lynchburgva.gov

900 Church Street, Lynchburg, VA, 24504, US

434-455-3800

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SURVEY REQUIRED


DISCLAIMER:

DO NOT leave blanks anywhere in this document. If the City of Lynchburg receives this document with blanks it will be returned to the sender for correction.

Home/Property Owner: Make sure that you have been in contact with an Insurance Agent, and have their contact information, including email address to complete this form. If a survey is required, make contact with a Surveyor or Engineer and have their contact information, including email address to complete this form.

Surveyor/Engineer: Please print Page 2, apply seal and return to Erin Hawkins, Water Quality Manager, Water Resources, 525 Taylor Street, Lynchburg, VA 24501 immediately upon completion.


Section A
Completed by Home/Property Owner: Upon completion of this section, the home/property owner will then email it to their Insurance Agent of choice.

Section B
Completed by Insurance Agent: Upon completion of this section, the document will be forwarded to the home/property owner who will then email to their Surveyor of choice to complete Section C & D, along with uploading property photos on Pages 5 & 6.

Sections C & D
Completed by Surveyor or Engineer (if required): Upon completion of this section, the document will be forwarded to the home/property owner to complete Section E and F. Surveyor or Engineer will print out Page 2, apply seal and return hardcopy to Erin Hawkins, Water Quality Manager, Water Resources, 525 Taylor Street, Lynchburg, VA 24501 immediately upon completion.

Section E
N/A

Section F
Completed by Home/Property Owner.

Section G
Optional - Water Resources

Pages 5 & 6
Photos can be uploaded to this area by Home/Property Owner (if survey not required) or by Surveyor (if survey is required).
Please check that you agree before continuing.
By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
Signature HereClick to Sign
Signature HereInsurance Agent Will Sign Here
03/02/2024
Signature HereEngineer Will Sign Here
03/02/2024
Signature HereProperty Owner (Part 2) Will Sign Here
03/02/2024
Signature HereWater Resources Will Sign Here
03/02/2024

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