HomeMy WebLinkAboutBLD2005-00103 ItUILDING PERMIT APPLICA N Review A05-110
Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00103 Received Date: 2/23/2005
SITE ADDRESS: 211 S JACOB MILLER RD
PORT TOWNSEND, 98368
OWNER: RICHARD A STAPF JR PHONE: 3 7/ ''.9✓ I
BEVERLY A STAPF
4677 BELL STREET
PORT TOWNSEND WA 98368
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001054013 Section: 5 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: WEic4 PHONE: 93 13f r
LOD Pr 3‘6
PROJECT DESCRIPTION NEW SFR &
A/G 1000 GALLON PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2,519
VALUATION 225,778.00 ADD'L: HEAT TYPE: RAD
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD 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: / 5 / 3
/ Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
APPROVED
�
Permit $1,699.35 BAC 02/23/05 71477 P V E
Plan Check $1,104.58 BAC 02/23/05 71477
State Building Code $4.50 BAC 02/23/05 71477 APR 1 9 2005
Potable Water Application $53.00 BAC 02/23/05 71477 Jefferson County Planning
Total: $2,861.43 &Building Department
• •
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00103 Received Date 02/23/2005
SITE ADDRESS: 211 S JACOB MILLER RD Issue Date 04/19/2005
PORT TOWNSEND, 98368
APPLICANT: RICHARD A STAPF JR PHONE:
BEVERLY A STAPF
4677 BELL STREET
PORT TOWNSEND WA 98368-1923
SUBDIVISION: Block: Lot: +
PARCEL NUMBER: 001054013 Section: 5 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
•
PROJECT DESCRIPTION: NEW SFR &
A/G 1000 GALLON PROPANE TANK
CALL IN FOR THE ' QUIRED INSPE/ CTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: i S-/lay/ .
UFFER: I s�
Footing: I .�02 y or'
Found- on. 6-/-D5-
Stormwate FINAL Approval:
Underground Plumbing:
Underground Insulation:
Shear Wall : MIAlVck'8`S
Sheathing:
Framing:',zCvtif'C�1fts l3yr",., 2/12'.: i.,11,)4.:tc 6:1.(:)L`•'t i!/1L tsi-Y j< `l/t /EJt
Plumbing y/i OC,
Propane Tank/ Lines: 1 •• Lips _'• 'i*4K t-4--Cfo iNT y/L/E�
Insulation:/4/ ••11- /7 /,
Sheetrock: /f., Jy p�
Septic Syte Finall Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
FinaliOccupancy Approval: if-G-o1 k )
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
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SPECIAL CONDITIONS FOR COE BLD05-00103
1.) 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.
2.) 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.
3.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
4.) 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).
5.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
6.) The building height is not to exceed 35 feet.
7.) Minimum setback from S Jacob Miller Rd right-of-way is 20 ft. Minimum side and rear
setbacks are 5 ft.
8.) 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.
9.) A minimum of two (2) on-site parking spaces are required for the single family residence.
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I:\F_BLD_Permit_Buildng.rpt 10/29/19
• oN �° JEFFERSON COUNTY
1 DEPARTMENT OF COMMUNITY DEVELOPMENT
, 621 Sheridan Street • Port Townsend •Washington 98368
O 360/379-4450 • 360/379-4451 Fax
a' http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
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MLA#
05— 7/.0 PROJECT/APPLJCANT NAME: A fl.:;f'.t«'T..4 r "',7,4 7p`2-,.
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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if ei! JF.cI;Wi0 ,P a.i'r+,i:" :•:.,, Zla!'1.�1't^6it'/+'"0 .or,e .S j;:ie.,E /'',A /Z , - (fflf 57zi.A.x,,,l
A?e. Existing e) 7/. e r`wt,•r�,"�t 4/11- - . 4,6,%4 C Flf"eA�r,,• r". 1 C f AC F,. r r . f,i4 •
Conditions Summary s' ,p 1 N E �, !�. ' '." , .t,`.
2. Describe the existing topography. Indicate contours on the site map.
CFA/Tz Y .SLOPiiI6. off-- s_ .i/teofs fzliL �2 Rn• 152;14Aty,.-l.f "4 > Y dF .62,..5:/E 7/7d//
�S75-s� - Q/ti:. 30, .- .®/Vr.t.V /;/lA d,,f/.4.//,,F,;1•/ /0 ' ir7-1 .,..'F G%11710rv; Af.,u/�" d�iF-1%r .44.;k'; •
/4[ e % . "2. feµ- 72/v 6'': /QS / /- 9. ' 72 J G ...;;/,fir- 4c le'r t;- D4i'4J
3. Describe the existing vegetation. Indicate native vegetation areas on the site map. 70"4'7-4 w"S-` �seafr. '1' 4-'''''''.1
EX/S774✓U- !/ '//3r/171vv.,l ,'.c 1 /f!,/ die /4•4 ,- 17;Am , "— . f A'�-c :,
r^.rjk 4-7:6-7/. ) i �J�.ca.,.ly y t "rj,I� �,^ 2 .r
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4. Describe the existing soils. Indicate soil type on the site map.
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 indicate acreage of each. y ,..
NO '4,r/l P�3 t"- ce. -y�,-� f.M -- if1t- /17;,w'"e6"«�..v';F✓:.; WAT 6'/J-Sr'7 F
6. Describe any excess levels of noise generated by the proposed use or activity:
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42.771//77
STORMWATF.R Pt AN
MAR - 9 2005
stormwater site plan template—rev.10/1/2003 5
JEFFERSON COUNTY
DEFT OF M1UN11I: /DF€� ,Qp,M
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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.
•
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.).
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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.
g. 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 the site plan and differentiate proposed facilities from existing facilities.
'�7►',;st'�`:%%r 1iJ:J - .:�, t�.4`_ �J��-.,N.. ..:-�J AY. .�i�Cz,^, :I.(`'°.�;
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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.]
11. Describe the performance goals and standards applicable to the project.
12. Describe the flow control system.
fit 447.
.
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stormwater site plan template-rev.10/1/2003 6
13. Describe the water quality system.
14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code. 4,
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17. Describe the proposed surfacing material.
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18. Describe methods,� for restoration of the site.
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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.
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:
4/4
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stormwater site plan template—rev.10/1/2003
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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.
2. Establish Construction Access. I/ �j /i /�//�
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7'xfr,'.: :fie oiv ,7 f/..'r S 5
3. Control Flow Rates.
fin � `J�r/ r P/1.:1 ,s"f---, /:V/
4. Install Sediment Controls.
5. Stabilize Soils.
— S 0 EXC4 74f-%7o J
6. Protect Slopes.
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7. Protect Drain!filets.
70!'
8 stormwater site plan template—rev.10/1/2003
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
„,
9. Control Po9utants.
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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.,erodibility,settleability,permeability,depth,texture,soil structure).
.44 ;^a c s, ✓ ; -a , ` .r c" - 4i:: ./
5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
/10
b. Pro osed wet season construction activities for environmentally sensitive areas.
l/
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation ,
impacts.
4
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps. /
b. Diversions. it,f
c. Waterways. /
d. Runoff/Stormwater Detention Calculations
I
stormwater site plan template—rev.10/1/2003 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 ected property.
(LANDOWNER OR AUTHORIZED EPA ENTATIVE SIGNATURE) (DAT
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stormwater site plan template—rev.10/1/2003 12
• OWNER BUILDER STATEMENT
The signer of this stater?ent does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assu • g tje r ponsibili k of the -neral Contractor for the proposed project. /
Signature: •, 4 Date: Z 2g Q5
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:&.' )
MAILING ADDRESS: EMAIL' FEB 23 -2flJ5
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) `?FAX:( ..'ll,;,-
MAILING ADDRESS: EMAIL • " '
Project Type: Frame Type: Bathrooms: ,horeline: Type of Sewage Disposal:
X New A Wood Existing: ❑ Sewer } c-, ,' ✓
❑ Addition 0 Steel Proposed: 2•5 Ba ❑ Community System r.-
❑ Alteration/Remodel 0 Concrete Total: 2.5 Heig : A Individual System
❑ Repair ❑ Masonry SEP Permit# SErrs:1,f--OOLz'{
Bedrooms: ?)
❑ Demolition 0 Other: Water Supply: U P''
Existing: Setpack: ❑ Private well ❑ Two Party
Type of Heat: Proposed: -3 �f $ Public
FADrAtJT Ft<oo� Total: _,3 r Name of System: C,IT( OF
Po,2r 'Tar✓ws�',.rt7
tfthisisaCommercial Project you must answer the following: --^^
Number of Parking Spa Current: Proposed: Number of ADA earkingSpacar
Number of occupants(includes o Hants,employees,etc) Current ..--...--------Proposed
'M r IBC Occupancy: IBC Type of constructi Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installatirif"r'`i'per ,.mark all items below that apply:
❑ Underground Tank AAbove 9found'Tank Size of'r'dpane,Tank: l,01Y)
❑ Heat Stove t Cook$ove'.D Woodstove Fireplace Insert yt Hot Water "alik Pellet Stove yel_ Other EC t1-F g,
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No -,...„,,,,—
When applying for a permit to install a propane tank you must also submit a site plan showing all of th buildings,all property
line,$;tank location and size,distances from the propane tank to all property lines,buildings and septic system c61Spoaents,
"Including the reserve area. ',..
Square Footage For',Office Use Only -s� . tx
Current Pro osed Amount Syr{k a e �c X.0_ ;
Main Floor Review F>r ,� ra,f - ����
r T & R
2""Floor54
�.` tt �-�; 4, � �� � u�
— . ase fee f- rv.. ;
y �€Srr � .
3`°Floorditignal Section: . '< .y, „ ' f ,
"av
Nt
Mezzanine: Plan'Check�feer r, Kt pliii:rit1:::
Heated Basement '. State�Su fee: , , ; ''
i 1 4��_•�l`Y.Y y..: � '
Unheated Basement PotWa ter RPevewfee s W iiii:,A 3
Y 4 . '
�
` X " ,4gf° + s A t,
Other Unheated 811/R�� fe'' 4 � �„`r ° f' , 1 4 ' 4
`;
Garage/Carport - • TOTAL;' '-,- . `{ �gx
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Decks Tt . . w G�* Er ai n l l- r k
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eceptNu! x ,;. i R./ .'.)`! , -Ay: ��
Other '.:05 �Cheot•Nume • 1 -� � ar "` v v FtiP
: tt k. ti C4 . 1 ^- at"ESTIMATED COST(REQUIRED) Date; 34. r
•Fair market value of all labor and materials foundation to finish �' 1h y
I vot 000 :Inlitias _• • _ r=, , , ;_
1 pLt d�..i .
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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N cbcN cod, JEFFERSON.UNTY
' \-‘ 1j, DEPARTMENT OF COMMUNITY DEVELOPMENT
'N ' '4 621 Sheridan Street• Port Townsend •Washington 98368 1
360/379-4450 • 360/379-4451 Fax
Off' www.co.jefferson.wa.us/commdevelopment
N FEJ 2 3
Master Permit Application _M)<A: Ill ` LP I ID
Project Description(include separate sheets as necessary):
51W-rt.-E. 11PAAIr_Y gESIDf G __:.:..__..._. .. . .v... . ._: � -
Tax Parcel Property /V/ 70/. 60
Number: Op I d 51i 0 t 3 Size: y 8'6 iiek "S (acres/square feet)
Site Address and/or Directions to Property: 2 I I S S. Tac c)B fN ILLt✓te- RD•
Property Owner(s)of Record: Qt(..44A RID A. STA PF„i.
Telephone: 3104 - 379- 53 55 Fax: J email: S-fc cy 4)-ca..S I e 5 pc.44,collet
Mailing Address: Z.i( S• 3AGo g M tt.L.E FZt
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
X Building ❑Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
XI Single Family ❑ Discretionary"D"or Unnamed Use Classification
- Garage Attached i )etacher, ❑ 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**
❑ 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 ❑ 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 attorneys 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 re .1r-• later inspections.Access and right try to this.-rty shall be requested and shall occur only during regular business
hours. �
Signature: • •' t.,_ «� Date: /I1 2" 73 e
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 indi '•ual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if y. -re in compliance with the Jeffers', ,unty developme•t code.The Applicant acknowledges that he,she or it holds individual
and non-transfe :1. responsibili fo ad ering to a • co.:plying :111
, s`,. he Applicant has read this disclaimer and signs a date it below.
Signature: / a. r rs • I Date: Z,i2/�s Z,�A---
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