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HomeMy WebLinkAboutBLD2004-00494 MLA05-00462 LDING PERMIT APPLICATIP1 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: r BLD05-00494 Received Date: 7/27/2005 SITE ADDRESS: MADRONA VISTA PL PORT LUDLOW, 98365 OWNER: PETER P HELFENSTEIN PHONE: 206-713-4009 CAROL HELFENSTEIN 502 RIPLEY LN N. APT 114 RENTON WA 98056 MADRONA VISTA 1ST AD SUBDIVISION: Block: Lot: 4 PARCEL NUMBER: 970300018 Section: 34 Township: 28 N Range: 01 E CONTRACTOR: STRUCTURE NORTHWEST PHONE: 425-869-2097 tAkc 4022 140 TH AVE NE BELLEVUE WA 98005 Contractor's License STRUCN*982C1 Expires 2/21/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr NSRF W/ATTACHED GARAGE &A/G 120 PROPANE TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,378 VALUATION 205,544.00 ADD'L: 713 HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: HTP OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: 14 CONST TYPE: 5N GARAGE: 462 SHORELINE: CONST TYPE: DECK: 295 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: LUDLOW BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 3 Total: 3 Total: 3 Routing Date: Q 1 11)5(1-- --- Type Amount Paid By: Date: Receipt: pprivoDOeEDat Potable Water Application $53.00 SLE 07/26/05 76358 P State Building Code $4.50 SLE 07/26/05 76358 Plan Check $1,031.78 SLE 07/26/05 76358 SEP 1 6 2005 Permit $1,587.35 SLE 07/26/05 76358 Jefferson County Planning Total: $2,676.63 , &$ ' Department 'et eci2o „hi.- A • BUILDING PERMITa. Jefferson County 621 Sheridant Street,Department of Community Developmentort SITE ADDRESS: BLD05-00494 (360 379 8368 101 MADRON -4451 PORT LUO A VISTA pL APPLICANT: LOW, 98365 Received Date PETER P HELFENSTEIN Issue Date 07/27/2005 CAROL HELFE 09/16/2005 502 RIPLEY LN NSTEIN SUBDIVISION: RENTON Wq g8066 PT 114 PHONE: PARCEL 206-713-4009 NUMBER: MADRONA VISTA 1ST AD 970300018 CONTRACTOR: Section: 34 Township: Block: STRUCTURE NORTHWEST 28 N Lot: 4 4022 140 TH Range: 01 E NE BELLEVUE A 9 00 WA 98005 PHONE: 425- Contractor' 869-2097 06 PROJECT DESCRIPTION: s License: CALL IN FORT RIPTION: NSRr'►�//HE REQUIRED ATTACH STRUCN 982C1 Expires: 2/21/E T SETBACKS: , I SPECTI• THAT APPLY 8A/ ,- G 120 P D� APPLY T PROPANE TANK UFFER: „Z .� O YOUR PROJECT. Footing: Or Foundation: KC Stor 23 mwater FINAL . Underground Plumbing: tubing: �orr,�,t did z Under ,.= ..' Underground Insulation: ' Shear Wall: -? " '� Sheathing: J �I'�1 z/�� Framing. Mm Ltej�. ��.'c'f Plumbing: �� • �' d'8 � Propane Tank/ �i3�q� Insulation: Lines: _ �� Sheetrock: '� ei �� s 1 .5. �1 .r" Septic Sytem Final Approval Road Approach Fina pprol: not on ZoningApproval: sewer): 3 aj��� Final Approval: Final/Occupancy Approval: 4 HEALTH DEPARTMENT AND: woR KS APPROVAL REQUIREDONE PRIOR TO FINAL INSPECTION LINE 379.44� CALLHOURS R IT MUST BE PROPERLY Office AVAIL 9 00 a.m.R 4:30 ADVANCE ANCE TO SCHEDULE HOT LINE ABLE 24 E INSPECTIONS. S APPLY-SEE REVERSE SPECIAL CONDITIONS FOR CIE A BLD05-00494 1.) The southern foundation wall must be a minimum of 36'to the south property line for placement of the primary and reserve drainfield areas P y 2.) Critical Aquifer Recharge Areas may require special protection measures to mitigate quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the water Management Practices (BMPs) and facility design standards as identified and defined the Stormwater Management Manual for the Puget Sound Basin. s q , all new Best 3.) To help prevent seawater from intruding landward into underground aquifers, in 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. 4.) 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 standards, there shall be no cross connections allowed between the potable supply impounded water. water 3. Water withdrawn from wells on each propertyPP Y and and/or gardens. shall not be used for watering of lawns 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 (xerisca in we P g, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive but is intended to be illustrative of the types of water conservation measures. 5.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: rather 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 6.) MANDATORY MEASURES FOR COASTAL SIPZ: 1. For proof of potable water on a building ab a permit application, applicant must utilize DOH-approved public water system if av 2. If public water is unavailable, a qualifying alternative system may potable water or an individual well may be used as proof of potable water subject to the following requirement: be used as proof of a. Chloride concentration of a laborato building permit application. rY-certified well water sample submitted with 3. If public water is unavailable, a qualifying alternative system may be used as r potable water. 7.) MANDATORY MEASURES FOR AN AT RISK SIPZ: proof of 1. For proof of potable water on a building DOH-approved public water system if avai able it application, applicant must utilize 2. If public water is unavailable, a qualifying alternative system may be used as potable water or an individual well may be used as proof of potable water subject to the following requirements: proof of a. Chloride concentration of a laborato building permit application. rY-certified well water sample submitted with b. Installation of a flow meter. c. On-going well monitoring for chloride concentration. d. Submittal of flow and chloride data to the County per monitoring program. 3. If public water is unavailable, a qualifying alternative system may be used as potable water. (per list maintained 8.) The property owner shall comply with Water Conservation Measures proof of by the UDC Administrator). ----..nimemmenimmimmi 9.) The project shall adhere to t� erosion and sediment duringBest Management Practices (BMPs) to stabilize soil exposed construction. BMPs shall address permanenta colt measurestormwater and drainage l sdurin construction, and in the design e 10.) A Stormwater Site Plan has been submitted and a g and operation of stormwater Community Development.fully De the provisions t. Once the subject permitd proved been the De has issued the Department of implement f Community Developmentplanand contact the JeffersoniCoun shall Department oce, to arrange a schedule to ins planes compliance. compliance.Aertificate of OccupancyCounty see until plan cn No clearing forrawa not utilities issued until the on ththe e for site measures have beenforo the installation roadways or shall occur o Department necessary o me installation of temporary sedimentation and erosion 11.) Outdoor residential storageproject fire, safety, shall be maintained in an orderlye 12.) Not more thanatwoor sanitary hazard. manner and shall create no thantrea acre (2) unlicesed or inoperable vehicles shall be stored on one-halfrights-of-way. Such screeninglesstotally screened from view of standards specific shall meet all a neighboringany lot less to the district in which the storage dwellings and the character of ee area. performance l and in keeping Code(UDC) Screening shall meet the requirements of Unified Development► ent Section 6. kept, and shall be in keeping with vehicles is Outdoor storage of thirteen prohibited except in those districts where s1 sp3)ecified more unlicensed ilr wrecking yard or junk (or salvage) yard and allowed as a Permitted inas aninoperable storage shall meet the re UDC Sectione Use 4.10.Tablen 3 automobile of UDC n such unlicensed or inoperable requirements of UD (ESA), perable vehiclesbe stored in an Environmentally ent In no 13.) Maximum lot coverageEnvironmental) case, shall any impervious surface oes notltodeS exceed Y as amounte ofAfea 14.) mThp buildingLot coverages, cois concrete, defined height is not to exceed 35 feet.' driveways, concrete, etc. 15.) Exterior lighting for residential uses shall not exceed finished grade, excepting when such lighting is annte twenty feet(20') in height from Ground level lightingx ist oncosts 16.) Lighting fixtures shall be designed Brae part of a building the directly visible fixtur from be de the boundaries of the or structure. gold and hooded to prevent the light all lighng during intensity from being le of surrounding and after project completion property. 17. g properties or adjoiningmpletion hall not adversely r rightness of Minimum setback from tights-of--way. and ur Madrona Vista Place Y affect the yard setbacks shall be 5 feet. right-of-way 18.) A minimum of two shall be 20 feet. Minims residence. (2) on-site parking spaces shall be Minimum side provided for the single family ':IF BLD_Permit_Buildng.rpt 10/29/19 I ' f/ „• , , 6 JEFFERSON COUNTY i DEPARTMENT OF COMMUNITY DEVELOPMENT:" l AUG _ 2005 k 621 Sheridan Street • Port Townsend •Washington 98368 1 360/379-4450 • 360/379-4451 Fax http://www.cojefferson.wa.us/commdevelopnnent/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# (0 5— 1-4 (o 2— PROJECT/APPLICANT NAME: CZ-Ache - OPAA. t c` 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. �y y�y� q l �,�t, �rGT fl.`7 4 l't'l_c j o r c i -' �t v 1 ,wri.(l.r 1,--e c-A %tf' c.) tr—ai i-ect--} i Dr-r, 64— • 21 , lit i2 c= . t--( .U-e,(, Existing Conditions Summary 2. Describe the existing topo raphy. Indicate contours on the site map. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. 11Y1CY)4-1 L.1 1 c t' c S f'-"kl' �, .t. .• \,(1l Ytr Je . _ 4. Describe the existing soils. Indicate soil type on the site map. SXi\(-)C t✓I [CiC-I In'/ / 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 acres a of each. 5 41r't l U t� 2 rJ t �t �. �1 1'1 6. Describe any excess levels of noise generated by the proposed use or activity: r,4 ( V t t-v\et 1O t S 4'— �S -k-kA v^17 rk v\ tMCVC Iv\ v` c • _l I. e'p Lkt ROVED STORM WATER PLAN stormwater site plan template.doc—rev.10/12/2003 AUG 2 3 2005 5 Stormwat Require JEFF CO itTY DEPT.OF ! Pit .NT SIGNATURE: 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. .`-'5till al (1,C>c het,. r C, � I�� \A/ C e L" h t t k • ei'f r) 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 slopes,etc.). '- 4 A A I?ac J c )1 r -1/P_ pivi e t� A1} 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 exi g facilities. "c—ti c\ t_ e -e d e.ti s ory -0 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 sy tern. -tt A wclk _� 5, {LY miG — 3 2005 I. stormwater site plan template.doc-rev.10/12/2003 -- 6 13. Describe theme 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 f Yz-- -I- 5 , - i i Rc,-k.. (,- AV V O e;�k 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. . -t 'hc)e_. - - iyA 17. Describe the proposed surfacing material. 0-47.YV -✓`' u / -4--t I r c rtbrl c1 -4 1 k_ '' Sp;( 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. )(5 P - 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. Ail A 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 h restrictions re. !T ri � JTf � y ��,, i AUG 3 2305 i. 1 I stormwater site plan template.doc—rev.10/12/2003 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. ' r-t u - "f (. e.- t— ' iA I C31�t al I A � ' I. _ Z�. P mil , a't_ ..G - 2. Establish Construction Access. t=,a---t 5-A-1 n t, 3. Cantrell ow Rates. 4. Install Sediment Controls. c v r + ---(�e4f\c_Q Cho Lk)ri ©p e. +A 5. Stabilize Soils. P CO VV-4r-- `0 - rM ii is t.,,/ p l L s i--t( 6. Protect Slopes. Dr C e-4 7. Protect Drain Inlets. 1 i ,, 1 j? 1:TT ' ' AUG - 3 2035 I i ',i 1 stormwater site plan template.doc—rev.10/12/2003 i8 I • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. — 9. Control Pollutants. Nit 10. Control De;Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management P actiices(BM's). l� E -O F i 1 raf 6 17- n 12. Manage the Pr jest. //�� 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). PI- b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). Ai A 3. Environmentally Sensitive Areas./Jo ( �,z (�' a. Description of environmentally sensitive areas that are on or adjacent to the sit .t l- �. L v Air- AUG - 3 Z005 stormwater site plan template.doc—rev.10/12/2003 9 b. Description of special requirements for working in or near environmentally 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). 5. Construction Phasing. a. Construction sequence t n ct t�JJt> bt riJ � RJ 1TJbf-3 C� V"l lQ:ll<, r T.-bur flc c. tici\ . ►i-S -rt�. -ei_A it.; cCcuins krd_P/ham- iL( - ,,vie f4l Ic ) b. Const#uction phasing(if proposed) 1-tA— ct, r -i tVd.ih i V . 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). Provide a proposed construction schedule. i&i+i CIS 4 ny-uc ( si Lz tk.f a- v. b �j c�vti i kr-e 11,4 r:r(tom` krk t k CMG �l `_��- y-��r P_� c�e j�t..) II. Wet Season Construction Activi4s. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. n()A 7. Financial/Ownership Responsibilities. a. Idg=perty own r responsible for the initiation of bonds and/or other financial securities. ,,fP b. Describe bonds and/or other evidence of financial responsibility for liabilit as n Ion impacts. ', AUG - 3 2Uu i 1. • 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. c. Waterways. p d. Runoff/Stormwater Detention Calculations C-Ch At''ya;ti-kl e -'f f'(X o e Se /tt1Ab 1 ) Zt1)i6.. p i!of)c�d -�`- stormwater site plan template.doc—rev.10/12/2003 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 the affected roperty. ---- e,.,j 6/, -A)6- (LANDO NER OR AUTHO IZED REPRESENTATI SIGNATURE) (DAT THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 1 r '.7- r '- 41 ,-, • .. ;iy 4., I . E, ,J1E1-).-, f 1i I! , AUG - 3 2.005AUG - 3 1 I L.._ _ . stormwater site plan template.doc—rev.10/122003 12 K--, ---erilik6, \ JEFFERSON CIINTY IP 4 ,.j DEPARTMENT OF COMMUNITY DEVELOPMENT. '� 621 Sheridan Street • Porte w �N end -Washington a3 360/379-4450 • 360/379-445� �qs104). ,s0� www.co-jefferson.wa-us/cam velopment C IND (< Master Permit Application JU L. 2 6 2005 {` ��." MLA: os - `Pa Project Description include sep rate sheets as necessary): 'e 9t4 e.iti ,(, vt)( A-14 A + -G--zAcf:64 Tax Parcel , Number: 970 (+(i ) Property j Ci Size: I`'Z (acres/square feet) Site Address and/or Directions to Property: , . .-7-" 4 /t Dj .i(4j 1/,'.57 L 4/CJC Property Owner(s)of Record: 7 7L 7- A.,,, T 6/A/ Telephone: .264:` 7/,3 - ley; el Fax: , No email: A, v-- Mailing Address: i5Z%,�/ /& )/v L .L,t A,% t% //4/ `ib)(J Applicant/Agent(if different from owner)r' 1i7Cz:*../ 11E,0j/it 7((,L_/A I Telephone: ,RJ;( 7/ 3 •-j1�1 C >rT y,,, Fax: 2t1..5`-- 8 6Cl •�Gc'7 email: 17LC-K , [r��;y� l�¢c•^/�;:A,r, Mailing Address: NC What kind of Permit?(Check each box that applies) )uilding ❑Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj** 1Ktingle Family ❑ Discretionary"D"or Unnamed Use Classification Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** ❑ ManufactuteTTI-Time 0 Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑Commercial* 0 Binding Site Plan** ❑ Change of Use ❑ Long Plat** ❑Address 0 Road Approach 0 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 0 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 x"C 4-eve £/A '��',re:Al-to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Y _ Date: i - 2-3 63` 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 fa:t 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 u review and a required later inspecti .Access and right of entryto this purpose of businesssstion hours. 9 property shall be requested and shall occur only during regular Signature: , a/ / Date: :7 " 2-5-— (�=5 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-tra ble resp sibili for adheringgtb-and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: ,� t-u `ra Date: - 7 -- .S` cr,5-'" G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 0 OWNER BUILDER STATEMENT . The signer of this tement does her y certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be as�/su- ng the r ponsibil of the Genne�ral Contractor for the proposed project. Signature: `X�� LL C.Y— Date: 7 - ,s -' (.) _._.- _ tom/ GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: c7AL'CTn,ic� ,VI: („2“") l/ .3• 46 ('SUIT -c 7 7 MAILING ADDRESS: :a2 -/ 7 Ci. . teklg AJ,1&' • EMAIL: RLCI<- JJ6/tj E-y t(_ i/Zc Aj .At-7 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: G Y Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: '"-'/ Height: 4ndividual System ❑ Repair ❑ Masonry SEP Permit#.56P Oi-0')/`V4 ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party T�,e of Heat: Proposed: \.3 Public C`t�G. . r friFA -pi ri(}' Total: T3 Name of System: POD I 1-1-31-)I/ 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 X Above ground Tank Size of Propane Tank: n Heat Stove , Cook Stove ❑ Woodstove sz( Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / o,' _ _ When applying for a permit to install a propane tank you must also sulf frti site plan showing all i f tltq buildings,all property lines,tank location and size,distances from the propane tank to all prrpe lines,buildings and 1ept slyftem components, including the reserve area. - Square Footage For Office Use Only i t ' 1? is • Current Proposed ,I U I 2 6 ant ` ' Main Floor nsisteOcy Review: 3 76 ia3 51o. 1 _ 4Q•CO 2Nu Floor ) gal fee: �7/25-(CO 8(0). ( 5$"1. 3fd Floor ) Additional Section: Mezzanine: Plan Check fee: t D3I -1 Heated Basement State Surcharge fee: 4-5D Unheated Basement Pot Water Review fee: (Z I. Db Other Unheated (.9"tillICI Approach fee: 14 t7' OD Garage/Carport Dr�Qn.� TOTAL $ . A �06• (05 S. Decks ;y,5- (0 Q t leceipt Number. I COD �7 Other v_ci x 14 i • cgCasb!Check Number: 00 ESTIMATED COST(REQUIRED) Dom' al0 ��S •Fair market val of all labor and materials foundation to finish r`,�7 C� �� � Initials: R05,5+3 ��G:\PermitCenter\FORMS\DRD FORMS\Master Pe pplication 7-8-04.doc • v� 7' Cl LA I. co , l ;* v.". (e) 4 „ ••• V. 4 • jir .1 ,C" • ;„ ; v 1 . 0.). x ; -b* • ‘C*8c I V cs' • e4 tz) ic 0 ( (7 . 51 ›- 1 t . , 1-t -7 I 1110:1 Lkriv--1 -I r1--ct I ‘z. (11- r • r'-1 ? c-- 4-4 .4•! -1. ;• t _ 6 ' (it . t•-1 _o ti• . _ _411, NJ 2 r :siNs I I ° Ft '1 •s• I r e„ 77`ti 4,07 -ek .!4.1P)121-roki (LT2_4:: : /4/ • icA) . .1) s — _ . r ir ' 7 E0 to tp ›P: r- g ?-. C/3 tr 3 • G-) °Hrii j4 ct e e * tri co et 777 ip N.> 0 • • 1)1 4 - t.t Us i E I) -I ,c73 § NC ftl .71 11. — • • • 1. ._ __...... . �,M _ .. ... My Cn 1. 2)4 / co...-......--......1 1 Cirl U' .1 N. A t 1.).\ . 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