HomeMy WebLinkAboutBLD2005-00599 • 0
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00599 Received Date 09/16/2005
SITE ADDRESS: 287 ADELMA BEACH RD Issue Date 10/28/2005
PORT TOWNSEND, 98368
APPLICANT: MATTHEW S HENERY PHONE: 360-379-1318
TARA L HENERY
1705 14TH ST
PORT TOWNSEND WA 983688200
SUBDIVISION: Block: Lot: TXG2
PARCEL NUMBER: 001324079 Section: 32 Township: 30 N Range: 01 W
CONTRACTOR: LITTLE & LITTLE CONSTRUCTION PHONE: (360)385-5606
2009 4TH STREET
PORT TOWNSEND WA 98368
Contractor's License: LITTLLC157C5 Expires: 2/28/2007
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE A/G 500 GAL PROPANE TANK
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: Utc 6243-'G , PI.
UFFER: ()Vt.-. a-e-66 4
Footing: 0- - o'er P
Foundation:' .M t.t.. NAS Pam-*. Pc4,43 X la,_ is o;
Stormwater FINAL Approval:
Underground Plumbing:
Underground Insulation:
Shear Wall : 5kr�.Z,2 2.06
Sheathing: // ,
Framing: I - - - • IP.IIPM -
r /
Plumbing:
Propane Tank/Lik�es: ww -74Vk -c .�„nliG �7/6
Insulation:_��fiY/ 0 6
Sheetrock:O�i UU�>117).40
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: _s-p2S 0
HEALTH DEPARTMENT D PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY - SEE REVERSE
SPECIAL CONDITIONS FOR COE # BLD05-00599 1111
1.) 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 Water withdrawn from wells on each property shall not be used for watering of lawns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 Ground water withdrawn from each property shall be restricted to a rate of three (3)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.
2.) 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.
3.) 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.
4.) 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.
5.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
6.) 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).
7.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
8.) The building height is not to exceed 35 feet.
9.) Minimum setback from Adelma Beach Rd right-of-way is 20 ft. Minimum side and rear
setbacks are 5 ft.
10.) 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.
odimmelpi
11.) Lighting fixtures shall be desk ed and hooded to prevent the light source fr m 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.
12.) A minimum of two (2) on-site parking spaces are required for the single family residence.
13.) 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.
I:\F_B LD_Perm it_Bu ildng.rpt 10/29/19
• BLD05-00599
ItUILDING PERMIT APPLICATION
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00599 Received Date: 9/16/2005
SITE ADDRESS: 287 ADELMA BEACH RD
PORT TOWNSEND, 98368
OWNER: MATTHEW S HENERY PHONE: 360-379-1318
TARA L HENERY
1705 14TH ST
PORT TOWNSEND WA 983688200
SUBDIVISION: Block: Lot: TXGZ
PARCEL NUMBER: 001324079 Section: 32 Township: 30 N Range: 01 W
CONTRACTOR: LITTLE & LITTLE CONSTRUCTION PHONE: (360)385-5606
2009 4TH STREET
PORT TOWNSEND WA 98368
Contractor's License LITTLLC157C5 Expires 2/28/2007
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE A/G 500 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,450
VALUATION 500,000.00 ADD'L: 2,340 HEAT TYPE: PRO
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: EEE
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 890 SHORELINE:
CONST TYPE: DECK: 480 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 4 Prop: 4
Total: 4 Total: 4
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
State Building Code $4.50 SLE 09/14/05 76584 APPROVED
Plan Check $2,101.94 SLE 09/14/05 76584
Permit $3,233.75 SLE 09/14/05 76584 OCT 2 8 2005
Total: $5,340.19 Jefferson County Planning
& Building Department
• •
OWNER BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
4-1'4-4.1 t_ -/- L i•j-+t.c,. £o..4s{-YU c.{--•u•-ti (3(io )3b5 - hoc. Woo)31�s - 17 33
MAILING ADDRESS: ZVo of y4 y `7 G 17 t'4 EMAIL: g I e K a I i 'Hie I, T-41 e.. C go`�
CONTRACTOR'S LICENSE WAINS /
NUMBER: LX-T L L..G.1• 7 _ NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
<New Wood Existing: I I Sewer
Addition ❑ Steel Proposed: Bank I I Community System
i l Alteration/Remodel ❑ Concrete Total: Height: )Individual System
❑ Repair ❑ Masonry SEP Permit# ds "/C7C.
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: i 1 Private well 1 1 Two Party
T e of Heat: Proposed: Public
Total: Name of System:TV D tt 1
e Y1 C.—
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 Pro•ane Tank.. id/or A• •liance Installation •ermit mark all items below that a• •I .
1 Un ound Tank ' Above ground Tank •-'s Size of P .•-•e T.nk: aw•
Heat Sto Cook tov- I Woodstove Fireplace Insert I Hot Water Tank j Pellet Stove i Other
s this a••lianc- •• • installed in a Manufacture• •• e Ho • - ,o
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only
Current Proposed Amount
Main Floor u +�350Consistency Review.
'ek el
2 Floor �O Base fee:
3ftl Floor I Z-370 do 1.13t 31 a33,`ir.
/ Additional Section:
Mezzanine: Plan Check fee: / R
Heated Basement 1 ' `
/ State Surcharge fee: 1
Unheated Basement Pot Water Review fee: 1
D 05-• t611
Other Unheated / 911/Rd Approach fee: ___------•Garage/Carport f TOTAL: $ /G�
Decks 0 lQ ci I 0 A n 9'� 51 -3 I
qbc7 it 1313 u Receipt Number: 1/_5 R
Other ash/Check Number: UJ�J ��1
31I acqof
ESTIM I Date:
•F • market value of all labor and materials foun tion to finish 1 9 1 os
S.- 0j000 Initials: /
C:\Do • op Master Permit Application 7-8-04.doc
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/��ON c'p • •
749 / 1 G JEFFERSON COUNTY
7;� ,a DEPARTMENT OF COMMUNITY DEVELOPMENT
'` '� 621 Sheridan Street• Port Townsend • Washington 98368
.. �. 360/379-4450 • 360/379-4451 Fax
.gSNG,O www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: 0,555(7
Project Description(include separate sheets a1snecessary):
•
� Size:Tax Parcel t ` �Ti �)�. Lr✓r1 r 1 t-�';.rG�(.Ice
Property /
�V\ 3 y� C5'j �
Number: 437 751 BOO (acres/square feet)
Site Address and/or Directions to Property: ZE.-] A(•e j h / .e,(^ En��
Property Owner(s)of Record: -�•�F•�•.{LA, t j e v,�r .. H evs✓r"-y
Telephone: 3C1'o -3x1- 13Iis Fax: email:
Mailing Address: lIoS Pita 54- B'r•1- 7:ow.4_'S.e.4.,rok
Applicant/Agent(if different from owner): L.1"44t t.. 4' Li 4-+Lt Cv..s.--- C A k,X L.i 4 4i6')
Telephone:-Lst? 3A5-SGCite Fax: 34,o 3 `-4.733 email:4I C)C 2,l i 141e- 1►441e&coo,
Mailing Address: ZCPOI 11"LA S•F VC,be. 4- Tc Srt KA
What kind of Permit?(Check each box that applies)
)uilding U Variance(Minor,Major or Reasonable Economic Use)
Ll Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj**
Single Fa c• ❑ Discretionary"D"or Unnamed Use Classification
arage 'ttached Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufact -. -. e ❑ Boundary Line Adjustment
❑ Modular El Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑ Address i 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
li Temporary Use El Comprehensive Plan/UDC/Land Use District Map Amendment
Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment
Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known:
A
DESIGNATION OF AGENT
I hereby designate -�'�, L.1 ' -ksz.__ to act as my agent in matters relating to t s ape ication for permit(s).
AVM a.
OWNER SIGNAT - Pam./-•, Date: r
By signing t is applicati.- ,the o. /ag-nt attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it'. .a. -age. . erial 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.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.Signature:
YSignature: 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 respo i ility for adh rin� o nd complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature:i t , ' Date:
C:\Documents and Settings\mochtl\Desktop\Master Permit Application 7-8-04.doc
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1
JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
i
i
_ ` "-, , 621 Sheridan Street • Port Townsend •Washington 98368
gS, N6) 360/379-4450 • 360/379-4451 Fax N t
http://www.co.jefferson.wa.us/com mdevelopment/ _
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# PROJECT/APPLICANT NAME: t4 t vt4. tr y e6:ettµ��
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. �7��_v•AS'}"11,f.�- ✓t.�, K� _ �i Isd,3 Lc.. •Fti..,�ay F-�,s_ ��r.
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Existing Conditions Summary
2. Describe the existing topograph . Indicate contours on the site map.
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
A LA e x 1''S'1"-t 1. 4..6f6 1-7-1-I l.O� -�,k t(-) 1-g-F- ,c--
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.
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6. Describe any excess levels of noise generated by the proposed use or activity:
STORMWATER PLAN
stormwater site plan template.doc—rev.10/12/2003 OCT 1 1 O 5
JEFFERSON COUNTY
DEPT.OF '1T NY+D2M N
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.
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.).
S;dss Gt d - . - '5s styrct-J
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.
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.]
1
11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow
control system. ,/ (�
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stormwater site plan template.doc—rev.10/12/2003 6
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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.
"la,...) be- 8,.s•- Ju,h,- -t �'� C� fit: . lot -? (. .t
h
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.LLIroteK Got l Co ►motpa c -�-►�•-� e
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17. Describe the proposed surfacing material.
18. Describe methods for restoration of the site.
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4-LA.A_ cow ;l :-) �,r,1d (44 #1 bsiig -,c 4-Pv"._.% ,y
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. )0lA
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.
stormwater sfte plan template.doc—rev.10/12/2003
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.
2. Establish Construction Access.
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.doc—rev.10/12/2003 r
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
401 9. Control Pollutants.
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
IvCA
11. Maintain Best Management 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).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
1/5
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stormwater site plan template.doc-rev.10/12/2003
b. Description of special requirements for working in or near environmentally sensitive areas.
i p st off-
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).
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5. Construction Phasing.
a. Construction sequence
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).
Provide a proposed construction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
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.
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
r ! 1 4
stormwater site plan template.doc—rev.10/12/2003 10
•
1
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 property.
4-46 -- °l/3/
OR UTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stormwater site plan template.doc-rev.10/12/2003 12
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