HomeMy WebLinkAboutBLD2005-00035 GILDING PERMIT APPLICAIN MRLA05 00030 eview Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00035 Received Date: 1/18/2005
SITE ADDRESS: 672 RAINIER LN
PORT LUDLOW, 98365
OWNER: CHARLES RODEN PHONE: 360-301-0619
JAMES NELSON
PO BOX 65160
PORT LUDLOW WA 98365
SUBDIVISION: PORT LUDLOW NO. 3 Block: Lot: 63
PARCEL NUMBER: 990700063 Section: 17 Township: 28 N Range: 01 E
CONTRACTOR: M C RAYMOND-BUILDER LLC PHONE: 360-301-1700
1163 BLAINE ST
PORT TOWNSEND WA 98368
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEWSFR W/ATTACHED GARAGE,COVERED PORCH &
A/G 120 GALLON PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,290
VALUATION 244,230.00 ADD'L: 475 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: 5N OTHER: 709 SHORELINE:
CONST TYPE: GARAGE: 697 SETBACK:
DECK: 257 BANK HEIGHT:
SEWAGE DISPOSAL: SEW
WATER SYSTEM: LUDLOW PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: 3 Prop: 3 Seismic Streams
Total: 3 Total: 3 Flood Way Floodplain
Routing Date: / / F&W Landslide
/� Shoreline Aquifer
� 5 `� Forest: Commercial Rural
Type Amount Paid Bv: Date: Receipt: oved/Date
Permit $1,805.75 BAC 01/18/05 69118 / FF® M ED
Plan Check $1,173.74 BAC 01/18/05 69118
State Building Code $4.50 BAC 01/18/05 69118 MAR - 7 2005
Potable Water Application $53.00 BAC 01/18/05 69118 Jefferson County Planning
Total: $3,036.99 & Building Department
bloityietif, ro
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00035 Received Date 01/18/2005
SITE ADDRESS: 672 RAINIER LN Issue Date 03/7/2005
PORT LUDLOW, 98365
APPLICANT: CHARLES RODEN PHONE: 360-301-0619
JAMES NELSON
PO BOX 65160
PORT LUDLOW WA 98365
SUBDIVISION: PORT LUDLOW NO. 3 Block: Lot: 63
PARCEL NUMBER: 990700063 Section: 17 Township: 28 N Range: 01 E
CONTRACTOR: M C RAYMOND-BUILDER LLC PHONE: 360-301-1700
1163 BLAINE ST
PORT TOWNSEND WA 98368
PROJECT DESCRIPTION: NEWSFR W/ATTACHED GARAGE,COVERED PORCH &
A/G 120 GALLON PROPANE TANK
CALL IN FOR THE REQUIRED I SP CTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: O Fe-- 3iz o5 2
UFFER: /de
Footing: 0/- 3/2 oS kleon 3///GS d
Foundation: 043 s c Goo., i6o%i►s,"
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Stormwater FINAL Approval: k 6/7!!,5 '•
Underground Plumbing:
Underground Insulation:
Shear Wall : OK 7/is/O6 #(AJA/ciku JLY(J
Sheathing: /
Framing: Wj(,r„<J --)"�S-01C-'Fr1.
Plumbing: Of( liz7/QS,
Propane Tank/ Lines
Insulation: a i/pS oL�i
Sheetrock:
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: De 2/5/G,?
HEALTH DEPARTMENT AND PUBLIC WORKS APP- •VAL 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 CAA BLD05-00035
1.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
2.) 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.
3.) 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.
4.) 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.
5.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
6.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater,
erosion and sediment during construction. BMPs shall address permanent measures to
stabilize soil exposed during construction, and in the design and operation of stormwater
and drainage control systems.
7.) A Stormwater Site Plan has been submitted and approved (subject to attached conditions)
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.
8.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
9.) Not more than two (2) unlicense 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).
10.) Maximum lot coverage is not to exceed 45%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
11.) The building height is not to exceed 35 feet.
12.) Minimum setback from Rainier Lane right-of-way shall be 20 feet. Minimum side and rear
yard setbacks shall be 5 feet.
13.) Exterior lighting for residential uses shall not exceed twenty feet (20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
14.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
15.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
16.) Per MPR Code Section 3.107, Accessory Dwelling Units (ADU's) shall not be allowed
within the MPR-SF zone.
17.) IN ADDITION TO ROOF DOWN SPOUT DRAINAGE CONTROL, A FOOTING DRAIN
SHALL ALSO BE INSTALLED THAT EXTENDS AROUND THE ENTIRE HOUSE AND IS
DRAINED BY A TIGHTLINE TO THE RAINIER LANE ROADSIDE DITCH IN A
SEPARATE TIGHTLINE.
18.) THE DRIVEWAY INTERSECTION WITH RAINIER LANE SHALL BE GRADED SUCH
THAT WHEN RAINFALL FLOWS DOWN THE DRIVEWAY THE WATER IS DIVERTED
TO RAINIER LANE ROADSIDE DITCH. THIS SHOULD BE DONE TO PREVENT
WATER FROM FLOWING OUT ONTO THE STREET AND INTO NEIGHBORING
PROPERTIES.
•
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Require _ Aii\ ' APPROVED
g.Sozv e ' ST RM Wes. R PLAN
°��, JEFFERSON COUNTY to co t, r 01_5
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,� DEPARTMENT OF COMMUNITY DEVELOPMENT MAR 7 2005
621 Sheridan Street • Port Townsend •Washington 983
�! 360/379-4450 • 360/379-4451 Fax JEEP UNTY�R
47N0 http://www.co.jefferson.wa.us/commdevelopment/ DEPT.OF(' U,' Y :VF. O ENT
SIGNATURE:
STORMWATER SITE PLAN SUBMITTAL TEMPLL,
MLA# W - 00S _ PROJECT/APPLICANT NAME: Iry `/ifeiP L
Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the
applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a
separate stormwater site plan map.
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map. / / ,
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.t 4141A rett N� c r+« � •rf'7' S G 6$1.44.4._ s �o : r"6-1 L,4- •
3. Describe the existing a-1 vegetation. Indicate native vegetation areas on the site map.1�e GC tiS LC
4. Describe the existing soils. Indicate soil type on the site map./
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5. Describe the existing site hydrology(i.e.,drainage;behavior of water on the site—above,below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and
sindicate acreage of each.
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6. Describe any excess levels of noise generated by the proposed use or activity:
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stormwater site plan template—rev.10/1/2003 1 5
7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map.
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8.... ..:Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads,and sensitive/critical areas
(streams,) wetlands,lakes,steep slopes„etc.). / /� / ' / /� J
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
9. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on thg site plan and differentiate proposed facilities from existing facilities.
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10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
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11. Describe the performance goals and standards ��licable to the project.
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12. Describe the flow control system.
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stormwater site plan template—rev.10/1/2003 . 6
13. Describe the water quality system. d s
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
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17. Describe the proposed surfacing material.
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18. Describe methods for
�restoration of the site. r r p y /
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here.
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
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21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here. >A-
•
stormwater site plan template—rev.10/1/2003 7
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I—CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will.be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page
2-15).
•
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits.
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets.
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stormwater site plan template-rev.10/1/2003 8
12 Required Elements-Construction SWPPP(continued)
8. Stabilize Channels and Outlets.11" / f p
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9. Control Pollutants.
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10. Cd trot De-Watering(the acted pumpiypg groundwater or stormwater aww y from an active construction site).
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11. Maintain Best Mana ement Practices(BMPs).
12. Manage the Project.
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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stormwater site plan template-rev.10/1/2003 9
b. Description of special requirements for working in or near environmentally sensitive areas.
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4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,eeerodibility,settleability,permeability,depth,texture,soil structure).
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5. Construction Phasing.
a. Construction sequence �,¢
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b. Construction phasing(if proposed)
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule. Levi-Lei-/e Fe.�+�:��w-y '-H 4* & /
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II. Wet Season Constructidn Activities.
a. Proposede � wet season construction activities. J J
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b. Proposed wet season construction activities f r environmentally sensitive areas.
////4
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
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b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions.
c. Waterways. ,
d. Runoff/Stormwater Detention Calculations !'
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stormwater site plan template—rev.10/12003 10
Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the
�afff affected p rty.
`(LANDOWNER OR AUTHO IZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
•
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JAN182005
stormwater site plan template—rev.10/1/2003 12
1/MIA
igcb , JEFFERSO UNTY I 4i ^7 7, ` _,I
DEPARTMENT OF COMMUNITY DEVELOPMENT r II
`4 621 Sheridan Street•• Port Townsend ••Washington 983t 8 l i
JAN 1 8
� � w
360/379-4450 • 360/379-4451 Fax f 2005 '`-,`
,q O ww.cojefferson.wa.us/commdevelopment
;ti.
Master Permit Application MLA: '`;.
Project Description(include separate sheets as necessary):
Tax Parcel h a - Property 5 FE
Number: `7 l✓ j 'r (acres/square feet)
Site Address and/or Directions to Property: t 1Z. I Pc r si ER 1--N, F-'0d- Lubi_OW, WI • '1 j 0 5*
Property Owner(s)of Record: :JAM.ES V, NEL.- QjsJ / 61-4-AcaL�- G, j /)FA1
Telephone: _.7X)]• 0019 Fax: email:
Mailing Address: P:O . Rol( (05 d(00 Po RI- 4-UJ L3IN, WA ' ci€)"5(p5
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)
❑p emolition Permit ❑Conditional Use[C(a),C(d),or C]**
V§ingle Fam' ❑ Discretionary"D"or Unnamed Use Classification
Garage ache /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)IAmendments**
'$ropane ❑ 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 ❑ 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:
DAP i O P PLL 3LZr I,,iv ki<S/ C E /Rrvt:T
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 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 Co my and its employees,representatives or agents for the sole purpose of application
review and any required later inspections.Acrpas and right of en to this property shall be requested and shall occur only during regular business
hours. /, /�
Signature: C '(( 1 • 1.-- / /111� Date: � /'"405
The action or actions Applicant will undertake as a result.:offthe 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
a e the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if y u are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-tran ble/r ponsjbili hering to n. ..mplying with th SA. The Applicant has read this disclaimer and signs and dates it below.
Signature: 1(�4 �yti�� �l�(� Date: /—V ' ,-)
G:\PemritCenter\FORMS\DRD FORMS\Master Pecri�it Application 7-8-04.doc
OWNER BUILDER STATEMENT
The signer of this statement does hereby certify that ey are the Owners of the parcel referenced herein,that they-are not I censed cc tra for end ha
they will be assuming the responsibility of the General Contractor for the proposed project. " I-• ,`` t l ` ,1
c
Signature: Date: _ i E
cIAN182005
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: I
/V\i C., RAII/Vi
1 ldEK ELL, (? 3OI I700 ( )
MAILING ADDRESS: I I(I FADES 1-. Ref of TutAim EmmL: A,- 9 („ ,
CONTRACTOR'S LICENSE WAINS
NUMBER: MC. FL Cf e,) MT NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: F9me Type: Bathrooms: Shoreline: Type of Sewage Disposal:
V New W Wood Existing: ceSewer
❑ Addition ❑ Steel Proposed: ` -.5 Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: Z, t Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition 0 Other. Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: 3 Public
HE-A--rptiAt P Total: "3 Name of System:of-mpr�
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 rAbove ground Tank Size of Propane Tank: I 7-0 C-1"1 cL-
❑ Heat Stove ❑ Cook Stove ❑ Woodstove Fireplace Insert ❑ 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'UsiiOnly Y 'ii :47:770
Current Proposed Amount e, �,� f ,t,'
4
Main Floor consistency Review: �,� T �``�� _ { �•
11L iO 1t.56 ,7r; �s4� =' t : ` ,ti:
2NO Floor _ Base fee:
3M Floor Additional Section: ,'- 'd' ",
Mezzanine: Plan`Ch ck fee: ' � "
Heated Basement State Surcharge:fee: ;P A C=
Unheated Basement Pot Water:Review fee: f. ' w ', ,- ,
Other-Unheated- CO va n 911/Rd Approach fee: k :' � t ..
291_- g.a e/Gacpert la 1 7 itc4.,25 TOTAL• $ 3 I )Ct`� ; �`, � " • 4, ;,
k yys0 axe-
Decks Receipt Number ' ``"r
Other 10 j < a j/t ��Q/ /, Cash/Check Number , 4 ;_ '- ',-ts ,'
ESTIMATED COST(REQUIRED) I ate: s , ,..,
.Fair mark t value of all labor and materials foundatk ish r k
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Applicatcm- II4.doc