HomeMy WebLinkAboutBLD2006-00097 •
CERTIFICATE OF OCCUPANCY
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451 (800) 831-2678
Al Scaif, Building Official
PERMIT #: BLD06-00097 Issue Date: 03/17/2006
SITE ADDRESS: 60 LILLY LN PORT TOWNSEND, 98368 Final Date: 3/22/2010
APPLICANT:
WILLIAM E RANGE PHONE: 360-316-9239
PATRICIA B RANGE
60 LILLY LN
PORT TOWNSEND WA 98368-2618 Block: 157 Lot: 26-29
SUBDIVISION: IRONDALE
PARCEL NUMBER: 962115707 Section: 35 Township: 30 N Range: 01 W
PROJECT DESCRIPTION: NSFR & PELLET STOVE
Remove garage & breezeway from plans 10/29/09
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2003 EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes n�o�
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 3/22/2010
10/29/19
I:\F_BLD_OccuPancy.rpt
JILDING PERMIT APPLICATIN MLA06-00096
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00097 Received Date: 3/6/2006
SITE ADDRESS: 60 LILLY LN
PORT TOWNSEND, 98368
OWNER: WILLIAM E RANGE PHONE: 360-316-9239
PATRICIA B RANGE
2546 HAINES ST
PORT TOWNSEND WA 98362 IRONDALE
SUBDIVISION: Block: 157 Lot: 26-29
PARCEL NUMBER: 962115707 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NSFR W ATT GARAGE BY BREEZEWAY & PELLET STOVE
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 252,932.00 MAIN: 1,416
CODE EDITION: 2003 ADD'L: 1,052 HEAT TYPE: EEE
OCCUPANCY: R_3 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: 5N OTHER:GARAGE:
SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: 432 BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 3
Total: 3 Total: 3
Routing Date:
-3 1 .7 A U9- b-1-2
-
Type Amount Paid By: Date: Receipt: A �� �, d
Permit $1,850.55 LYK 03/06/06 79140
VEr
Plan Check $1,202.86 LYK 03/06/06 79140
State Building Code $4.50 LYK 03/06/06 79140 MAR 1 1 2006
Potable Water Application $55.00 LYK 03/06/06 79140 Jefferson County Planning
Total: $3,1 1 2.91 &Building Department
•
•
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Pcrt Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00097
Received Date
PORT TOWNSEND, 98368 03/6/2006
SITE ADDRESS: 60 LILLY LN
Issue Date 03/17/2006
APPLICANT: WILLIAM E RANGE
PATRICIA B RANGE PHONE: 360-316-9239
2546 HAINES ST
PORT TOWNSEND WA 98362
SUBDIVISION: IRONDALE
PARCEL NUMBER: 962115707 30 N Range:
157
Section: 35 Township: Lot: 26-29
01 W
CONTRACTOR: OWNER/BUILDER
PHONE:
PROJECT DESCRIPTION: NSFR W ATT GARAGE BY BREEZEWAY 8 PELLET STOVE
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS:
UFFER:
Footing:
Foundation: N.A.A1
Stormwater FINAL Approval: /8
Underground Plumbing:
Underground Insulation:
Shear Wall :
Sheathing:
Framing:
Plumbing:
Propane TKO(/ in s:
Insulation:k Z.
Sheetrock: —�
Septic Syt Final A proval MUST be obtained before fiial of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval:
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 SCHEDUL
Office Hours 9:00 a.m. -4:30 E INSPECTIONS.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY - SEE REVERSE
SPECIAL CONDITIONS FOR CAI A BLD06-00097 •
1.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
2.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
3.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
4.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
5.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
6.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater,
erosion and sediment during construction. BMPs shall address permanent measures to
stabilize soil exposed during construction, and in the design and operation of stormwater
and drainage control systems.
7.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
8.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
9.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any l
less
than one-half acre unless totally screened from view of neighboring dwellings and
rights-of-way. Such screening shall meet all applicable performance and development
standards specific to the district in which the storage is kept, and shall be in keeping with
the character of the area. Screening shall meet the requirements of Unified Development
Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable
vehicles is prohibited except in those districts where specified as an automobile wrecking
yard or junk (or salvage) yard and allowed as a Permitted Use in Table 3-1 of the UDC,
and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any
such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area
(ESA).
10.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
11.) The building height is not to exceed 35 feet.
12.) 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.
13.) 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.
14.) A minimum setback for 20 feet is required from Lilly Lane right-of-way. Side and rear yard
setbacks shall be 5 feet.
15.) A minimum of two (2) on-site parking spaces shall be provided for the singel family
residence.
I:\F_BLD_Permit_Buildng.rpt
10/29/1999
! ,
r PERMIT #.11116 R b- (c� `
t JEFFERSON COUNTY MAR — 2a06
�. ki DEPARTMENT OF COMMUNITY DEVELOPMENT IrC
• 621 Sheridan Street • Port Townsend•Washington 98368 LIU 1l�i v i r'"it t t i"'1�
O 360/379-4450 • 360/379-4451 Fax
http://www.co.jefferson.wa.us/commilevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# 0 0- l Ip PROJECT/APPLICANT NAME: j?A2T 1 /3
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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 stomiwater site plan map.
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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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.
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6. Describe any excess lev
els of noise generated by the proposed use or activity:
fin?..4.0 ii!, ,,A r_._�-,- A),.1-',4 y I i;�}-7e.� -! �. D,� '"v-:<./,/ _
.1". {�,." APPR V -
STORMWAIER PLAN
Storrs MAR 1 7 2006
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,t
steep slopes,etc.)on the site. Indicate location on the site map. ,(
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8. Describe thegeneral vicinityof the site, includingadjacentland uses and structures,utilities, roads,and sensitive/critical
� cen c cal 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 facj)ities from existing facilities.
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10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
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11. Descrbe the performance goals and standards applicable to the project. Z.Eigi 0
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12. Describe the flow control system. ?
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stormwater site plan template—rev.10/1/2003 6
13. Describe the water quality system.
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MAR - 8-20
14. Describe the conveyance system analysis and design. 1 i s F •
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15. Describe the sour a of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
17. Describe the proposed surfacing material.
18. Describe methods for restoration ofythe site. /1
19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here.
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
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21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here.
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7
siormwater site plan template—rev.10/1/2003
}
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.
2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls. ,,,
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5. Stabilize Soils. a
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6. Protect Slopes.
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7. Protect Drain Inlets.
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stonnwrater site plan template—rev.1&1/2003 8
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
9. Control Pollutants.
1V
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs). i
MAR "' 6 2"�mot,'`
•
12. Manage the Project. - f p r n
r t� i pit �tly ! l i i.:l.
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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 ale on or adjacent to the site.
lm -
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).
5. Construction Phasing.
a. Construction sequence
b. Construction phasing(if proposed)
1 . I\
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
II. Wet Season Construction Activities.
a. Propo?ed wet season construction activities.
b. Piopose0 yet 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. hiAR
,,„
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. .
c. Waterways. j
d. Runoff/Stormwater Detention Calculations
stormwater site plan template—rev.10/12003 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
corm to the pe¢t of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owner of theafff'cted property.
(1: t—.--
(LA DOWNER OR ESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
RECEWvE D
MAR - 6 2006
JEfFERSO►N COUNTYOcO
stormwater site plan template—rev.10/1/2003 12
. oN °o
4 � JEFFER�I COUNTY 110
+.a, DEPARTMEVT OF COMMUR�I Y'®$I1[ 0MENT
,- 4 '4 621 Sheridan Street • Port Townsend •Washington 98368
& , > �y 360/379-4450 • 360/379-4451 Fax
14,9 �O www.co.jefferson.wa.us/commdetWOnive,trINC 2006_
Master Permit Application MLA: C), - c1 (�
Project Description (include separate sheets as necessary`s:
(fi - ;-)4- (Icj<_ -
Tax Parcel Number: '1 -7 Property (V io VI ee 2f,-,- -
(':' 2-, I i C - _7 f, -1� 1 Size:
/ (acres/square feet)
Site Address and/or Directions to Property: (- U j_t I I e,
Property Owner(s)of Record: 7-)i.1 t 4- fat' gG,-r ��a n e <,`'� �(,( i 1k` / -�1-� Q _a�(G b
Telephone: j(a o 'i lb et Z 3c1 Fax:
_ email:
Mailing Address: 2--y4:) t\c.,11ety .< - r,--,,n(,•
Applicant/Agent(if different from owner):
Telephone: Fax:
email:
Mailing Address:
Whit kind of Permit?(Check each box that applies)
[U Building ❑Variance (Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
ri��ingle Fa tY ❑ Discretionary"D"or Unnamed Use Classification
U4aragt'Attache Detached 0 Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Bounda
❑ Modular ry Line Adjustment
CI * ❑ Short Plat**
❑ Change of Use ❑ Binding Site Plan**
❑Address ❑ Long Plat**
❑ 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**
0 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 attorney's fees and
expenses which may in any wayd accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to ovide accest;and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any re fired later irispections.Access and right of entry to this property shall be requested and shall occur only duringre
hours. regular business
Signature: ;L.-A- 6..-1.-' 4---••
Date: 5 7 - C (-
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 Speck 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 of violate tht EPA. 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 adhe ing to and complying with the ESA. The Applicant has read this disclaimer and sans and d yes it below.
Signature: , t-- .-`\ -- _ '
Date: (
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
IBUILDER 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.
r �' l� C�
Signature: ij l i_.:. / . . �- Date: 3
GENERAL CON RAbTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
1. ( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE �" j W I S
NUMBER: T/ ?c . .- t2(Q• ,c.c 1,- 't.t)R 4�L`{9 NU ER
---�7,Lc, ._ 3 j- 3113 ARCHITECT/ENGINEER: elev FAx: (3
HONE (�u) Z 2( c44 (0o)2Z/ �cri., , � ,, .�; � ,q;�r��.K.P
MAILING ADDRESS: 'C ' z: _. liii L1;=,w'fe ( L.h} YS5 Z ) E44AIL JS A Y"Lk`,� U.,h;Ck 9l'.� , :_
Project Type: Frame Type: J - athrooms: Shoreline: Type of Swage Disposal:
(/New N./Wood Existing: ❑ Sewer
Fl Addition Li Steel Proposed: Z-• `> Bank Height: ❑ Community System
H l Alteration/Remodel ❑ Concrete Total: Z , j t A i4ndividual System
I.I Repair ❑ Masonry " SEP Permit# `..)c Pc S-0o2KS
U Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: I Plivate well ❑ Two Party
Type of Heat: 1, Proposed: 3 [`i'fublic 1
4.2& et-%r 4 Total: _3 Name of System: C l: 7
It 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-;7j '/i 'i
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:
C i Underground Tank $ Above ground Tank Size of Propane Tank: ( Z 0 _ (?
C! Heat Stove A Cook Stove ❑ Woodstove I I Fireplace Insert Li Hot Water Tank C] Pel ve 9i fir'-Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines, buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated _EH BId App Review:
t�{ ( (4; la.P. glk),0‘ ID`5. Dr)
2"° Floor Heated Consistency Review: � ' ���
` 052 ° ) 'U).1( 1 �3 DC) Stec
I
Other Heated ase fee: q �—
Mezzanine Additional Section: 1 '
Heated Basement Plan Check fee: aoa, C ,_,
Unheated Basement State Surcharge fee: 1 '1 c �1
Other Unheated we i?zc,Jc..x ` vie f. Pot Water Review fee: b�
��' cra �A,,L 1t
Garage/Carport i SUBTOTAL rz36"
Decks t 911/Rd Approach fee: r��QG J "��
Other I TOTAL: $ t ,�-;a) I 3:t)
Receipt Number: Fj g / LID q 10(03
gash/Check Number: V
� , 1005
ESTIMATED COST(REQUIRED) �a 101
.Fair market value of all labor and materials foundation o rush
Initials:
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