HomeMy WebLinkAboutBLD2006-00235 • •
MANUFACTURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD06-00235 Received Date: 5/4/2006
SITE ADDRESS: 192 KELLY DR Issue Date: 6/28/2006
PORT LUDLOW, 98365
APPLICANT: DIANE M SIMMONS
1591 N HIDDEN GLEN RD
PO BOX 18633
TUCSON AZ 85715
SUBDIVISION: CEDARHOLM VILLA Block: Lot: 16
PARCEL#: 942300007 Section: 19 Township: 27 N Range: 01 E
CONTRACTOR/ BUY RITE HOMES PHONE: (360)479-0795
DEALER 3543 W STATE HWY 16
PORT ORCHARD WA 98367
Contractor's License BUYRIH*0840B Expires 5/20/2008
PROJECT DESCRIPTION: NEW MFH W/ATTACHED RIVERHOUSE PORCH INSPECTED BY L& I
MODEL KR 61103/SERIAL NO. 27693
MAKE: KARSTEN
YEAR: 2006
SIZE: 61 X 28
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 6/28/2007.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOIJR PROJECT.
Setbac s/ ooti g (CONTINUOUS F)OTING, SLAp_or PADS USED): b� (...(c )(7)(7?Dr/S-
1 (o wp Ai o S«T— OUC�`
Stormwater FINAL Approval: PER, Le ri t rtes./ Et•utoiegme pore 6/B 07
Blocking/Plumbing: ?LesCgIt C/TIE- DatoNS OK 4/131d7 ilPropane Tank/Lines `
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps: Oi! 4/13/67 ,;
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL RE* IRED 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
I) • MLA06-00223
Review Type:
MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00235 Received Date: 5/4/2006
SITE ADDRESS: 192 KELLY DR
PORT LUDLOW, 98365
APPLICANT: DIANE M SIMMONS PHONE: (520)886-1603
1591 N HIDDEN GLEN RD
PO BOX 18633
TUCSON AZ 85715
SUBDIVISION: CEDARHOLM VILLA Block: Lot: 16
PARCEL NUMBER: 942300007 Section: 19 Township: 27 N Range: 01 E
CONTRACTOR/ BUY RITE HOMES PHONE: (360)479-0795
DEALER: 3543 W STATE HWY 16
PORT ORCHARD WA 98367
Contractor's License BUYRIH*084OB Expires 05/20/2008
REPRESENTATIVE: BUY-RITE HOMES PHONE: (360) 681-0777
259403 HWY 101
SEQUIM WA 98382
PROJECT DESCRIPTION: NEW MFH W/ATTACHED RIVERHOUSE PORCH INSPECTED BY L &
MODEL KB-61103/SERIAL NO. 27693
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: KARSTEN SETBACK:
VALUATION 80,588.00 YEAR: 2006
LABOR & INDUSTRIES APPROVAL?
SIZE: 61 X 28 BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
..C� � ��I � f
'`e App: ?nvEr
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $163.00 KAS 05/04/06 81162 JUN °10
2006
Potable Water Application $55.00 KAS 05/04/06 81162 Jefferson County Planning
Total: $218.00 & Building Department
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,JACK WESTERMAN Jefferson�dy Courthouse
ASSESSOR Po Ilox 1120. fort Townsend. SS':\ 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM rl
OWNER'SJ/in
NAME/MAILING ADDRESS: Y - 4
NAME: fna A/S , //i,AJ , CC 1rr nn rr�
IJNTY
ADDRESS:J59/ /(I. n1o%�l d/ i /d /L/Lis&) Jz 8s 7/
PHONE NO. 5 ZO-- 2 3 7 51s5
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1)MOBILE HOME DATA:
(A) MAKE /J i�,E'S TES (B) MODEL �.B ' //4 3 (C) YEAH ZOO
(D) LENGTH l 6 I (E) WIDTH 2.0 (F) SERIAL # 2-7L 93
(G)YOUR PURCHASE PRICE (Do not include sales tax)(Cr!) 5(98 PURCHASE DATE 31Z419 11
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE
ADDRESS
(B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes No
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year.
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No
(B)IF LOCATED IN MOBILE HOME PARK:
NAME & ADDRESS OF PARK Lot/Space #
(C) IF NOT LOCATED IN MOBILE HOME PARK:
NAME OF LAND OWNER: Si/21 m D.t)S , /4-kir
LOCATION ADDRESS /9Z- M //1/ / r tee a//O`d `d/Q
R L A PROPERTY PARCEL #/DESCRIPTION
I/ LZ 300 o07
ature of ap licant
THANK YOU FOR YOUR HELP!
?DSSe Q
6JO COSSELL, Property Technician
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SPECIAL CONDITIONS CASE # BLD06-00235
1.) PRIOR TO FINAL SIGN-OFF OF THE BUILDING PERMIT, THE ENGINEER OF
RECORD SHALL PROVIDE WRITTEN VERIFICATION TO THE DEPARTMENT OF
COMMUNITY DEVELOPMENT, DEVELOPMENT REVIEW DIVISION THAT THE
STORMWATER MEASURES WERE CONSTRUCTED PER THE APPROVED PLANS.
2.) THE GEOTECHNICAL REPORT PREPARED BY MORTA ENGINEERING AND
TESTING, DATED OCT. 3, 2005 (REV. B), REQUIRES A MINIMUM 100 FOOT
SETBACK FROM THE EDGE OF THE MARINE BLUFF. PRIOR TO SCHEDULING THE
FIRST INSPECTION THE LICENSED PROFESSIONAL. ENGINEER SHALL STAKE THE
100 FT. MINIMUM REQUIRED SETBACK.
3.) AS STATED IN THE GEOTECHNICAL REPORT, "THE SOILS ENGINEER SHALL BE
CONTACTED AT (800)590-0958 PRIOR TO CUTTING OR REMOVING ANY TREES TO
REVIEW THE CLEARING PLAN PREPARED BY THE OWNER OF THE PROPERTY. IT
IS IMPORTANT THAT ALL TREES ON THE MARINE BLUFF BE PRESERVED EXCEPT
FOR THE 100+ YEAR OLD DOUGLAS FIR THAT IS CURRENTLY LEANING
TOWARDS THE EMBANKMENT ON SOME TREES.
4.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat
management plan signed by WDFW June 22, 2005 and signed by Diane Simmons,
property owner, June 27, 2005.
5.) 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.
6.) The application was reviewed by the Jefferson County Department of Community
Development staff on May 26, 2006 for the potential presence of Environmentally
Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC).
After an initial Geographic Information Systems mapping review, the following ESAs were
confirmed to be present on the subject property: Eagle Habitat Area, Landslide Hazard
Areas (Slight, Moderate and High), Seismic Hazard (mapped along shoreline), Erosion
Hazard, Susceptible Aquifer Recharge Area, Coastal Seawater Intrusion Protection Zone
(SIPZ).
7.) A Geotechnical Engineering Report was prepared by Steven Morta, dated 10/3/2005 and
was submitted in conjunction with the stormwater permit application (BLD05-00115) to
address the Landslide Hazard Area. This geotechnical report also addresses the
residential development of the property.
8.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson County.
9.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
10.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
11.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular siould be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
12.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
13.) A vegetative buffer of 100-feet, as recommended in the geotechnical report, 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.
14.) A Geotechnical Report was submitted in conjunction with this application. The report
addressed the stability of the geologic hazard area. A minimum setback of 100-feet shall
be measured perpendicularly from the top or toe of the geologic hazard to the proposed
residential development.
15.) 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.
16.) 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."
17.) All construction activities shall not encroach upon the landslide hazard area buffer. This
includes the storage or preparation of materials.
18.) 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 by the UDC Administrator.
19.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water
quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs) and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
20.) 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.
21.) 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.
22.) 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.
•
23.) MANDATORY MEASURES Ft 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.
24.) The applicant is proposing to create or add 1,708 square feet of impervious surface and
1,708 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson
County Unified Development Code requires the project applicant submit a stormwater plan
meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater
Management Manual for Western Washington. The stormwater plan shall address
measures to control stormwater, erosion and sediment during construction and shall
address permanent measures to stabilize soil exposed during construction, and in the
design and operation of stormwater and drainage control systems.
25.) 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.
26.) An engineered stormwater 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 engineer of record to
arrange a schedule to inspect the property for plan compliance. A Certificate of
Occupancy will not be issued until the engineer of record provides original written
documentation to the Department of Community Development which 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.
27.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(1)(b)(i).
28.) The revised site plan as submitted on June 21, 2006 has been reviewed for consistency
under the UDC, and has been approved by Jefferson County Department of Community
Development. Any modifications, changes, and/or additions to the stamped, approved
site plan dated June 27, 2006 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
29.) This approval is for a new manufactured home only. Any future permits on this site are
subject to review for consistency with applicable codes and ordinances and does not
preclude review and conditions which may be placed on future permits.
30.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
31.) 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).
32.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
33.) Setback from Kelly Dr. right-of-way is no less than 20 ft., side setbacks are no less than 5
ft. Per the geotechnical report submitted a minimum 100 ft. setback is required from the
edge of the marine bluff. If an environmentally sensitive area (ESA) is present, then the
more restrictive setback shall apply.
34.) 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.
•
35.) Lighting fixtures shall be designed and hooded to prevent the light source fro 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.
36.) The building height is not to exceed 35 feet.
37.) The parcel has been designated Rural Residential 1:5 under the Jefferson County
Comprehensive Land Use Map effective August 28, 1998.
38.) This parcel was created through a Cedarholm Villa TractsPlat Subdivision September 3,
1907 recorded under AFN 25348, Vol 2, pp 119 of Long Plats with the Jefferson County
Auditor.
39.) Kelly Dr. (P82) is a private local access road. A road approach is not required. An
address of 192 Kelly Dr. has been assigned to the parcel.
40.) The geotechnical report requires a 100 ft. setback from the marine bluff. It states, . . .
when slides do occur the residence will be far enough back to be relatively safe for the life
of the structure normally 40 years."
Staff finds this meets the requirements for slope stability as setforth in Resolution No.
37-83.
. R
�gSON co o. JEFFERSUT�1 COUNTY lik -T.:1 A,'7.,' T)
f \ DEPARTMENT OF COMMUNITY DEVELOPMENT y
"4 621 Sheridan Street • Port Townsend •Washington 98361MAY - 4 2UU
360/379-4450 • 360/379-4451 Fax
��ys O . www.co.jefferson.wa.us/commdevelopment
AffEliSfiN CIi1i0: I
Master Permit Application MLA: NO-ad-3
----f
Project Descnp,on(include separate/sheets as necessary):
/
Tax Parcel Property
Number: Cf�z 340 *07 Size:
/, / 5 (acres/square feet)
Site Address and/or Directions to Property: 4.- . ker /"(d/o )
Property Owner(s)of Record: `,,,-yyi,yy1 nn-,O, f i ,A
Telephone: .. 2G - 67e, - /6[1 Fax: email:
Mailing Address: I?G. ,6n x /Z 3' j2 C;SDA✓ /2Z
Applicant/Agent(if different from owner): Bien -Z 7± 1/6/1/6:73
Telephone: '/I) -lc,ct'l--07 7 J Fax: 36.6 Z, /--O7"4'0 email:
Mailing Address:259 6)3 1//ciy /Lf/ c SL}Ct i4; /i/f9 98-58 21
Wh t kind of Permit?(Check each box that applies)
IY uilding III Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]'
0 Single Family I7 Discretionary"D"or Unnamed Use Classification
❑garage Attached/Detached 0 Special Use(Essential Public Facilities)**
wManufactured 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**
0 Site Plan Approval Advance Determination(SPAAD)* C] Shoreline Management Variance
0 Temporary Use C] Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* C]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 -et — f - to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE j '' / Date: -77 '�-C.� ,2`8' O c.
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 cf or in consequence of the granting of this permit
I further agree to p5 ' e access and rig f entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review nd any re ed later inspecti s Access and ri t of entry to this property shall be requested and shall occur only during regular business
hours.
Signature:
Date: ). //4
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 viojare the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if y are in com anol'with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and nog- ansf ere onsi ility r#hering to and complying with the ESA. The Applicant has read this disclai er d signs and dates it below.
Signature: fi.GC-C_< !i/� Date: � Q t_r'
G:\PemvtCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• ,
OWNER BUILDER STATEMENT •
The signer of this tement d 'hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be ass ing the i es 's'bility of the neral Contractor for the proposed project.
Signatt`ire: , t L Date:
ENE RAL CONTCTOR� OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
k _ � '14 yriPJ n (36,0 ) 1-6777 (,36()) 6 1 -078O
MAILING/ADDRESS: 2 5 C;f/-e) 1 <,j EMAIL:
CONTRACTOR'S LICENSE t/ . WAINS
NUMBER: ,Biz! xz-i-/*()8"//�, NUMBER yardcS'O2
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Prgject Type: Fra a Type: Bathrooms: Shoreline: Type of Sewage Disposal:
0 New VWood Existing: ❑ Sewer
O Addition ❑ Steel Proposed: Z Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: [Individual System
CI Repair ❑ Masonry 1 C y' SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: B'Private well ❑ Two Party
T e,of Heat: Proposed: . ❑3 Public
k'h Cr G� Total: ,3 /CO Name of System:
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 ❑ Above ground Tank Size of Propane Tank: --
0 Heat Stove 0 Cook Stove ❑ Woodstove 0 Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ 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 For Office Use Only C i-1"5 Pi1c NJ 5,
Current Proposed Amount- ,4
Main Floor i Consistency Review: `- `
2Nt'Floor ease fee:
3`°Floor , �(_,' t ddifional Section:
Mezzanine: y "Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement ater Review fee
Other Unheated 911/Rd Approach fee:
Garage/Carport -
1�( 1rt
TOTAL $ /��ry)
Decks "T: I 1
Receipt Number <1-:,'•
k
Other Cash/Check"Number: k ="1
ESTIMATED COST(REQUIRED) Y ,n• x,, T*-,,,,_,Ini'l+Date: ��`�.• 3 .,
•Fair market value of all labor and materials foundation to finish
SP, .5-5 . 60 Initials: (�
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