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HomeMy WebLinkAboutBLD2005-00438 II BUILDING PERMIT • Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD05-00438 SITE ADDRESS: 2063 THORNDYKE RD Received Date 06/29/2005 PORT LUDLOW 98365 Issue Date 09/19/2005 APPLICANT: ERIK B NORDSTROM 15�3 JULIE NORDSTROM PHONE: 206-373 4050 PO BOX 716 MEDINA WA 980390716 SUBDIVISION: PARCEL NUMBER: 721174008 Block: Lot: T15 + Section: 17 Township: 27 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE PROJECT DESCRIPTION: Semi-Htd Recreation Bldg CALL IN FOR THE REQUIRE IN PE TJONS THAT APPLY TO YOUR PROJECT. SETBACKS: dam. UFFER: Footing: ae" Foundation: Stormwater FINAL Approval: Underground Plumbing: , ',_ ;? DK 1OL; •� =' Underground Insulation: ff PK/ 7' e6 Shear Wall : Sheathing: Framing: ArrAMITIF Plumbing: . _L OK 4 18,04 !« Propane Tank/ in-;: )i' �i��'�l >►� Insulation: lf� /� _ _ o, j. A Sheetrock: ' Septic Sytem Final Approval (If not on sewer): Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPEC 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 INSPEC 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 CASE * BLD05- •00438 1.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 2.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 3.) Prior to and during approved construction activities, the perimeter of the landslide hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 4.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 5.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or any other prominent physical marking approved 6.) Critical Aquifer Recharge Areas may requires pe al protection mea ur slnistrator.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. 7.) 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. 8.) The identified Fish and Wildlife Habitat Area (Type 5 Stream), shall maintain a vegetative buffer setback of 50 feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to the proposed development. 9.) An additional setback of five (5) feet is required from the edge of the streamside buffer area to the proposed development. 10.) A permanent physical separation along the boundary of the streamside buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 11.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer- Do Not Remove or Alter Existing Vegetation." 12.) 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. 13.) VOLUNTARY MEASURES OF COASTAL &AT RISK SI : • 1. Installation of a flow meter. PZ. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 14.) 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. 15.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 16.) 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. 17.) A Stormwater Site Plan 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. 18.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 19.) 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). 20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 21.) The building height is not to exceed 35 feet. 22.) 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. 23.) 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. 24.) Minimum setback from private ingress/egress easement shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum rear(shoreline) setback shall be one foot for each foot of bank height, not to exceed 100 feet. Site plan depicts setback to exceed 50 feet. If ESA's are present, then the more stricter setbacks shall apply. 25.) Residential developers and individual builders shall be required to preserve shoreline vegetation and reduce the associated risk of erosion during construction and any future activity which may impact the stability of the shoreline. Al 26.) A Geotechnical Report dated 1Dfay 16, 2000 as prepared byAss1110 Inc. was submitted in conjunction with thefamily oclatrm EaThe re single port addressed the stability of the geologic hazard a ea. The proposed semi-heated recreation building is positioned further landward than the existing single family residence of which that setback exceeds 50 feet per the submitted site plan. I:\F_BLD_Perm it_Buildng.rpt 10/29/19 IUILDING PERMIT APPLICA!ON MLLA05 00410 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00438 Received Date: 6/29/2005 SITE ADDRESS: 2063 THORN DYKE RD PORT LUDLOW, 98365 OWNER: ERIK B NORDSTROM PHONE: 206-373-4050 JULIE NORDSTROM PO BOX 716 MEDINA WA 980390716 SUBDIVISION: Block: Lot: T15 + PARCEL NUMBER: 721174008 Section: 17 Township: 27 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI Semi-Htd Recreation Bldg TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,495 VALUATION 230,000.00 ADD'L: HEAT TYPE: RAD CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: 147 #OF STORIES: 1 OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: LUDLOW BEDROOMS: BATHROOMS: Exist: Exist: Prop: 0 Prop: 1 Total: Total: Routing Date: r • Type Amount Paid Bv: Date: Receipt: Approved/Date State Building Code $4.50 SLE 06/29/05 73456 APPROVED Plan Check $1,119.14 SLE 06/29/05 73456 Permit $1,721.75 SLE 06/29/05 73456 Total: $2,845.39 SEP 1 4 2005 rs County Planning in Department rOg. Wei) t,,6CA r • 1 e QN?\\ v EQ.__ •, ° JEFFERS�JN COUNTY �`, DEPARTMENT OF COMMUNITY DEVELOPMENT • 621 Sheridan Street • Port Townsend •Washington 98368 OHO 360/379-4450 • 360/379-4451 Fax http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# /"/L� J OS 06 4//D PROJECT/APPLICANT NAME: �J ,<�SIC�0 / C9 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. Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. J /� L/�`C Lf D`�, �, /7.�,,./5 �C'C-a.J r.rf�1-1 �/'✓C —( C-,----►Q / l /} ,/y`4 i l X f /G�-( ,is .i.r.... C•'a JYc," a"1 9' P ._ r/1--eG 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. / 5-4e 4 L --/ !"'telr �. /�E2--� ^. --t> CiCre,�,c yr- �7 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. ,/ p `�� -� 'I' /z"{�'-' !�' i��W J 67:2. / 6. Describe any excess levels of noise generated by the proposed use or activity: /70 z-, C_ APPROVED i 0 I E STORMWATER PLAN -, ` Stormwater i SEP - 6 r✓J Required SEP - 7 2005 stormwater site plan template-rev.10/1/2003 • • l 5 JEFFERSON C e NO' DEPT.OF k' t Yili LOPM. •r SIGNATURE: Ai i r ,-— — — —... _. _, I. Describe significal,• Jeoyrapoic ter.; ue., ana cntical areas (i.e., environmen tasy sensitivt areas such , ,vetiaiids, streams, steeplslopes,etc.)on the site. Indicate location on the site map. 1 A..„...--1/ es..--1 eiAlve,577C 5= M 741 7 b r/', 8. Describe the general vicinity of the site,including adjacent land uses and structures,utilities, roads,and sensitive/critical areas (streams,wetlands,lakes,steep dopes,etc.). t'/e —J. G.-1 / �-SA l•-i�' i4Cifr[ .— cv't !J" i ilr t-vcski 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 the site plan and differentiate,erentiate posed facilities rom existing facilities. r 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 ispersion of contaminants.] /� � is2E� C.�c*-- 4� p A c'd ‘ ..A/ ma`s" G1 yr /�•./ ",',l- ,/.7c c< S'o "---4 c'f ' //�/ Q A / 11. Describe the performance goals and standards applicable to the project. z 4y� j 4,‘..e-,,( c /7 12. Describe the flow control system. Zij 4lel SEP 6 20(5i ,) ' I stormwater site plan template-rev.10/1/2003 6 ■ r d 13. water quatt,y system. //4 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. / t f✓'t WI 4-C et v,ror 17. Describe the proposed surfacing material. /pot; ,tom 18. Describe methods for restoration of the site. 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. t 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 o4 contain more restrictive drainage-related requirements,describe those conditions or restrictions here. ti SEP - 6 25@5 stormwater site plan template—rev.10/1/2003 �„ --- . - 1 • 'r 'RUg .)RMWATER .LUTIONVI. ;(..W,._ 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 Accesss.. — 3. Control Flow Rates. 4. Install Sediment Controls. 5. Stabilize Soils. Yes 6. Protect Slopes. 7. Protect Drain Inlets. 11 ,, SEP f>_ 2005 , 1 •stormwater site plan template—rev.10/1/2003 r . 12 Required Elements—Construction SWPPP(continued- 8. Stabilize Channels and Outlets. 9. Control Pollutants. �Y� Gam_ 10. Control De-Waterin9(the act of pumping groundwater or stormwater away from an active constructions'e). �E�• / t ter y� l 11. Maintain Best Management Practices(BMPs). t/r� 12. Manage the Project. 2. Adjacent Areas. t4, a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). y b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). ; fit rA �.r/1;14 Cu /4,7 '=�7e #6,-4 /°L.C�f'sK 4 C Cf,.•-7Cj / y � � 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. • 3ty , v' A ,I t� S car t h 0/ +c s l ;\ SEP stormwater site plan template—rev.10/1/2003 9 . 1 u. Description of spe(-:,rl rc quiremen,,,for wa.Cnu it or near ow.nor;n»entally sensitive areas. 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). �lmL.4/e.Cttay/ J /6%. .o'c�CiG�jvt 5. Construction Phasing. a. Construction sequence /144 b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provided proposed construction schedule. II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. 7. FinancialOwnership Responsibilities. a. Ide ti a 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 ,ra ' s 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. n "''� b. Diversions. Q ^ — c. Waterways. r 4 d. Runoff/Stormwater Detention Calculations At C 1.f 1' „ SEP - 6 2005 E--'j stormwater site plan template—rev.10/12003 _J 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 constru io of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs (not standard on-site sto agement BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is completed. These shout 'rig 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 affected erty. , ,TE/0 4,_— WNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DA THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 11 SEP 6 20,Cr5 S A 12 stormwater site plan template—rev.10/1/2003 .�SO� c06,, JEFFERSON+�1NTY _ -,,� � DEPARTMENT OF COMMUNITY DEVELOPMENT I d< `4 621 Sheridan Street• Port Townsend •Washington 98368 I 360/379-4450 - 360/379-4451 Fax 1 ' , .yS,41N6�O www.co.jefferson.wa.us/commdevelopment i.i �_ ' JUN 2 0 2 r,j 1 Master Permit Application Project Description(include separate sheets as necessary): -`" J `-ft, L ICD1/ C-� _ __ __. Tax Parcel , ��,.`' � Property Number: i1 -72-1 1 1`TL-x Ps Size: (acres/square feet) Site Address and/or Directions to Prope (. T-lo+Z)Y i I'- . iZO __ Property Owner(s)1of Record: {,C'*' •11)L({„ KiC5ie.DETVO Telephone:(7O61 31 AO 5 Fax: email: Mailing Address: Applicant/Agent(if different from owner): (FP)a,-, i j � Telephone: ; -77'1^ 1 1 Fax: email: `,,,,,Oyt , Ct 3 Mailing Address: } 77 I Fi 4ui2 cL r/,'�FG 4..,.?7_ -4.,:. (,'l jlfQ O ` - G "J ) c' What kind of Permit?(Check each box that applies) Building 0 Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑Conditional Use[C(a),C(d),or CI** ❑ Single Family 0 Discretionary"D"or Unnamed Use Classification ❑Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**. CI 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 ❑ 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 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 its employees,representatives or agents for the sole purpose of application review and any required later inspections.Ames and right of entry to this properly 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 ("AVNER BUILDER STATEMENT he signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that the are not licensed contractors and that ley will be assuming the responsibility of the General Contractor for the proposed project. signature: Date: iENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) AAILING ADDRE : __ EMAIL: :OkffRACTOR'S LICENSE f`"_., WAINS l IIUMBER: -. t E NUMBER 1R 4 ITECT/ENGINEER: ':1 ,i 1 PHONE ( ) FAX:( ) MI NG ADDRES 2Q �d�5 > ti� •r` EMAIL _ _ 'roj T i�r CR �; .Fra Bathrooms: Shoreline: Typeof Sewage Disposal: 1 N w . Jl_FF '' �Iv 9 i.Or Gi vlU;�il'Y U,- Existing: 0 Sewer ii A ❑ Steel Proposed: i Bank ❑ Community System I Alteration/Remodel 0 Concrete Total: ! Height: ;Igf, Individual System Repair 0 Masonry SEP Permit# 7 Demolition 0 Other. Bedrooms: 1/ Water Supply: Existing: Setback: Proposed: X Private well 0 Two Party Type of Heat: Total: 0 Public Name of System: f this is a Commercial Project you must answer the following: lumber of Parking Spaces: Current Proposed: Number of ADA Parking Spaces: lumber of occupants(includes owners,tenants,employees,etc) Current Proposed BC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No f this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: :7 Underground Tank 0 Above ground Tank Size of Propane Tank: ❑ Heat Stove 0 Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other Is this appliance being installed in a Manufactured I 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 ` ? 1 Current Proposed Amount Main Floor ye ' o ns ly ev;ew: 4 .0 , 2Nu Floor / Base e:- 3 Floor Additional SecSotti, Mezzanine: 15L, 'fart Check fee Heated Basement • t k $" s Unheated Basement SIC tl,„,.:r.„14,,,,c,;.... , . ..,, , .. .. p r . . -. t- 40.., c . -:,„..4.4.:si.,,,A, ,t,r,..;.. , $.11lR ; ,. > s Other Unheated �, t� i Tr + i Garage/Carport . r t • {f '- .. Decks k4 W,Rtl • .1 w �j YG 'X T a .iC 4'.:. ,,,,,, !,a- Le y . �Other . 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