HomeMy WebLinkAboutBLD2004-00023 •
CERTIFICATE OF OCCUPANCY
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451 (800) 831-2678
Al Scalf, Building Official
PERMIT #: BLD04-00023
SITE ADDRESS: 200 NEVER GIVE UP RD Issue Date: 03/3/2004
BRINNON, 98320 Final Date: 6/7/2010
APPLICANT: ROBERT R BIRD TRUSTEE PHONE: (360) 460-3249
JOANNE L BIRD TRUSTEE
PO BOX 850
BRINNON WA 98320-0850
SUBDIVISION: BRINNON BEACH ESTATES Block: Lot: E
PARCEL NUMBER: 936100105 Section: 23 Township: 26 N Range: 02 W
PROJECT DESCRIPTION: Property line issues to be resolved by SUB03-39 prior to final sign off.
NEW SFR W/ATTACHED GARAGE & DECK(S)
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 1997 EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes no
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 6/7/2010
I:\F_BLD_Occupancy.rpt 10/29/19
illikUILDING PERMIT APPLIC ]ON MLA04-00017ReviewType: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00023 Received Date: 1/12/2004
SITE ADDRESS: 200 NEVER GIVE UP RD
BRINNON, 98320
OWNER: ROBERT R BIRD TRUSTEE PHONE: (360)460-3249
JOANNE L BIRD TRUSTEE
12942 SMALLWOOD AVE
DOWNEY CA 90242-4137
SUBDIVISION: BRINNON BEACH ESTATES Block: Lot: E
PARCEL NUMBER: 936100105 Section: 23 Township: 26 N Range: 02 W
CONTRACTOR: STEPHEN MOORE CONSTRUCTION PHONE: (360)460-3249
PO BOX 4173
SEQUIM WA 98382
Contractor's License STEPHMCO20L6 Expires 6/15/2002
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE & DECK(S)
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,656
VALUATION 244,775.00 ADD'L: 1,196 HEAT TYPE: PRO
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: 596 #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 1,200 SHORELINE:
CONST TYPE: DECK: 928 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUBLIC PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: 2 Prop: 3 Seismic Streams
Total: 2 Total: 3 Flood Way Floodplain
Routing Date: F&W Landslide
1116 j0 Yjice - Shoreline Aquifer
- Forest: Commercial Rural��
Type Amount Paid Bv: Date: Receipt: pP DeV E
Permit $1,805.75 KAS 01/12/04 62411 _
Plan Check $1,173.74 KAS 01/12/04 62411 MAR 3 2004
State Building Code $4.50 KAS 01/12/04 62411 Jefferson County Planning
Potable Water Application $52.00 KAS 01/12/04 62411 &Building Department
Total: $3,035.99
i
.(IS ANADeT ii-i °I
._
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD04-00023 iWkA.)\l/ Received Date 01/12/2004
SITE ADDRESS: 200 NEVER GIVE UP RDA ,J --( Issue Date 03/3/2004
BRINNON, 98320 rd • 1�'G'Y �5`-' <:,,�%t
APPLICANT: ROBERT R BIRD TRUSTEE 17jo L-";i/��( C� PHONE: (360)460-3249
JOANNE L BIRD TRUSTEE 7`'
12942 SMALLWOOD AVE
DOWNEY CA 90242-4137
SUBDIVISION: BRINNON BEACH ESTATES Block: Lot: E
PARCEL NUMBER: 936100105 Septiofi: 23 Township:`� 26 N Range: 02 W
CONTRACTOR: STEPHEN MOO ER CONSTRUCTION `�`'� — PHONE: (360)460-3249
PO BOX 4173 < rc �
SE,,CRTIM WA 98382 �, ‘+ `\,�r'i.
Contractor's License: STEPHMCO20L6 Expires: 06/20/2005
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE & DECK(S)
REQUIRED INSPE IONS'
SETBACKS:I 0 Y
X UFFER:� , x 6 fe
j>Q Footing: ' 161
Nii Founda ion:
gf Underground Plumbing:
Underground Insulaf n: _
Shear Wall : _
V Framing: ,� ci OS— C
jk Plumbing:
X Propane Tank/ Lines: j hire✓I o r ; O — 1. E-
jInsulation L Lt,3h 1--It-cis
Sheetro4 `.. � 1,2 6/6
D4 Septic S'tern Final Approval: :4 _ --
r 1 Road Approach Final Approval: Nhf
[ ] Zoning Final Approval: A//A
Final/ Occupancy Approval: `.? - ' ' f
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY -SEE REVERSE
•
SPECIAL CONDITIONS FOR CCE # BLD04-00023
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on January 20, 2004 for the potential presence of Environmentally
Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC).
After an initial Geographic Information Systems mapping review and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property:
Spotted Owls Habitat, Landslide Hazard Areas, Susceptible Aquifer Recarge Areas and
Coastal Seawater Intrustion Protection Zones (SIPZ).
2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson County.
3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
4.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
5.) Buffers are areas that shall be maintained in their natural condition, however, minor
pruning or alteration of vegetation may be permitted as long as the function and character
of the buffer are not diminished.
6.) Among the native conifer species which may be used in buffers or for re-vegetation
include, but are not limited to: Grand Fir (Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry(Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow(Saliz Lasiandra), and Scouler's Willow(Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry(Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant (Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sambucus Racemosa), Snowberry(Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium).
7.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
•
8.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
9.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water
quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs)and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
10.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three(3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
11.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
12.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
13.) The applicant is proposing to create or add 4904 square feet of impervious surface and
6950 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson
County Unified Development Code requires that your proposal submit a stormwater plan
meeting Minimum Requirements#1 through #5 of the Stormwater Management Manual
for Western Washington.
14.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i).
15.) The site plan as submitted with the building permit application on January 12, 2004 has
been reviewed for consistency under the UDC, and has been approved by Jefferson
County Department of Community Development. Any modifications, changes, and/or
additions to the stamped, approved site plan dated February 9, 2004 shall be resubmitted
for review and approval by Jefferson County Department of Community Development.
16.) This approval is for a single fatly residence with attached garage and decks only. Any
future permits on this site are subject to review for consistency with applicable codes and
ordinances and does not preclude review and conditions which may be placed on future
permits.
17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
18.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any lot less
than one-half acre unless totally screened from view of neighboring dwellings and
rights-of-way. Such screening shall meet all applicable performance and development
standards specific to the district in which the storage is kept, and shall be in keeping with
the character of the area. Screening shall meet the requirements of Unified Development
Code (UDC) Section 6. Outdoor storage of thirteen (13)or more unlicensed or inoperable
vehicles is prohibited except in those districts where specified as an automobile wrecking
yard or junk (or salvage)yard and allowed as a Permitted Use in Table 3-1 of the UDC,
and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any
such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area
(ESA).
19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
20.) The building height is not to exceed 35 feet.
21.) Minimum steback from Never Give Up Rd right-of-way is 20 ft. Minimum side and rear
setbacks are 5 ft.
22.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County
Comprehensive Plan Land Use Map effective August 28, 1998.
23.) A septic permit(SEP95-00364)was approved on December 29, 1995 and was finaled on
January 22, 1996 for a system of 1000 gallons per day.
24.) Never Give Up Rd is a private road (P393). The road approach is existing and an address
of 200 Never Give Up Rd has been assigned to the parcel.
25.) This parcel was created through the Plat of Brinnon Beah Estates - North Residential
Subdivision under AFN 367565, filed of record January 10th, 1994 in Volume 6, page
214-215. This plat was amended and recorded under AFN 416086, filed of record the 6th
day of November, 1998 in Volume 7, page 120-121 with the Jefferson County Auditor's
office.
26.) This proposal was sent to the Washington State Department of Fish &Wildlife (WDFW)
for potential Northern spotted owls habitat. WDFW found that the proposal did not conflict
with spotted owls habitat.
27.) A stormwater plan for a medium project has been submitted and approved by the
Department of Community Development. Once the subject permit has been issued the
applicant shall fully implement the provisions of the submitted plan and contact the
Jefferson County Department of Community Development to arrange a schedule to
inspect the property for plan compliance. A Certificate of Occupancy will not be issued
until the Department verifies plan compliance. No clearing for roadways or utilities shall
occur on the project site until clearing necessary for the installation of temporary
sedimentation and erosion control measures have been completed.
28.) A site visit of the subject property was conducted by Development Review staff January
30, 2004.
29.) A minimum of two (2)on-site parking spaces are required for the single family residence.
30.) There is a pending plat alteration application reviewing under SUB03-00039 to make Lot E
a more suitable building lot. This pending application shall not have any impact to the
building permit application since the proposal meets the bulk and dimentonal
requirements.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
ID JeffOf'SON Comelepartment of Ceiumiedty Development
orJ cow 621 Shen Street Port Townsend WA 00360[300]378-4450
r ., IA
a r` ,\_, 1� o
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Project Description: •
Building Type: oa Project Type: Frame Type:
- Single Family `~ Q New Wood
❑ Garage Attached/Detached " N ❑ Addition
❑ Steel
❑ Modular ❑ Alteration/Remodel ❑ Concrete
❑ Commercial Q ❑ Repair ❑ Masonry
❑ Multi-family/#of Units > ❑ Demolition ❑ Other:
❑ Industrial
❑ Other:
Bathrooms: Bedrooms: Type of Sewage Disposal: Type of Heat:
Choose one:
Existing: Existing: ❑ Sewer ❑ Community System 0 Electricity ❑ Oil
Proposed: a.,Al, Proposed: ----2— ,p Individual System 0 Woodstove ,i1.. Propane
Total: to, Total: —'4 If not sewer,fill out the following: ❑ Heat Pump
El Conventional 0 Alternative ❑ Other
Permit# SEP q 5-34.4-
Water Supply:
❑ Private well ❑ Two Party Well❑ Public:Name of water system: +.cw•.c , . tc.6k t3 \cs.\,,,w 14.- :\.h '(A,,;;;.. .
Square Footage: For Office Use Only
Main Floor \\0,..:lo 10 gte3• p �Z
Consistency Review 47;00-
2ND Floor \\t-1 I go7�. In Base fee I O S•7 5''
3=d Floor Plan Check fee—655% I I 1 3 -74
Htd Basement -" !! State Surcharge fee 4..50
Unhtd Basement $43• 3b Subtotal 3b 31 .C{ e
Garage/Carport \'CC ) trzs4.06 Pot Water Review fee gs--. 00
Decks 1 f . a-[ o lZ q,k7 911/Rd Approach fee -Cd.SC( IJ- .-•
Commercial W' �r ' TOTAL 31 t {o•.Rq
Industrial 24-`t 1� qU• �-' Receipt# b a C( (
Other Cash/Check#
Total Valuation: 0,t`17 J Initials
Or Date ` /L
Estimated Cost: 5 `a. �,o,fl
If within 200' of the Shoreline,
Distance to Bank or Ordinary High Water Mark ft.Bank Height ft.
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any
omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue
against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and it's employees,representatives or agents for the purpose of application review and any required later inspections.
Access and right of entry to the applicant's property or structure shall be requested and shall occur during regular business hours.
Signature: �R___� Date: I i d=q
OVER
H:HOME\PLNCNTR\INFOBLDG\FORMS\BLDpermitApplication 11-8-01
ON
4k�w; $ nor, JEFFERS�COUNTY • 11U N1103 NOSH3 31
DEPARTMENT OF COMMUNITY DEVELOPMENT
`4 621 Sheridan Street • Port Townsend •Washington 98368 '10Z 8 I I in
360/379-4450 • 360/379-4451 Fax
� p� www.co.jefferson.wa.us/commdevelopment
�`�iING
Master Permit Application MLA: ELi0 LI Vt
Project Description(include separate sheets as necessary):
Tax Parcel Property
Number: 1 -3 / o`' / v—� Size: (acres/square feet
Site Address and/or Directions to Property:
Property Owner(s)of Record: /<Uk1 ,k' r c is /%LJAl c 8 /l�
Telephone: . iv Q 7 2 cc> C 74 E 0 Fax: email:
Mailing Address:
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑ Building ❑Variance(Minor, Major or Reasonable Economic Use)
El Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑ Temporary Use El Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: Date:
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
OWNER BUILDER STATEMENT •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the respoonnsibili off the General Contractor for the proposed project.
Signature: 0 (G1- Date: / a C>
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:(
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
Total: Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
❑ Underground Tank ❑ Above ground Tank Size of Propane Tank:
❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert 0 Hot Water Tank ❑ Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only
Current Proposed Amount
Main Floor Consistency Review: `
2ND Floor Base fee:
3i°Floor Additional Section:
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport TOTAL: $
Decks Receipt Number:
Other Cash/Check Number:
ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish
Initials:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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