HomeMy WebLinkAboutBLD2006-00257 •UILDING PERMIT APPLICAIN MRLA06-002244
Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00257 Received Date: 5/15/2006
SITE ADDRESS: 70 LAUREL ST
PORT HADLOCK, 98339
OWNER: PATRICK D WAIT PHONE: (360) 379-4990
MARY L WAIT
70 LAUREL ST
PORT HADLOCK WA 98339 PORTAGE BAY PARK
SUBDIVISION: Block: Lot: 25
PARCEL NUMBER: 989100019 Section: 6 Township: 29 N Range: 01 E
CONTRACTOR: PHONE:
PHONE:
REPRESENTATIVE: TAMARA HALLIGAN PHONE: (360) 385-2628
PO BOX 862
PORT TOWNSEND WA 98368
PROJECT DESCRIPTIOI REMOVE EXISTING CARPORT AND REMOVE EXISTING SHED AND
CONCRETE
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2003 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUBLIC
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: 441 Approved/Date D
Total: ALJ I2006
JelItrsuni
& Budd*Department
• •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00257 Received Date 5/15/2006
SITE ADDRESS: 70 LAUREL ST Issue Date 8/1/2006
PORT HADLOCK, 98339
APPLICANT: PATRICK D WAIT PHONE: (360) 379-4990
MARY L WAIT
70 LAUREL ST
PORT HADLOCK WA 98339 25
SUBDIVISION: PORTAGE BAY PARK Block: Lot:
PARCEL NUMBER: 989100019 Section: 6 Township: 29N Range: 01 E
CONTRACTOR: TOLLEFSON BUILDERS INC PHONE: (360) 732-4080
PO BOX 100
CHIMACUM WA 98325
Contractor's License TOLLEBI977N9 Expires 3/15/2007
OWNER, PATRICK D WAIT PHONE: (360) 379-4990
if different: MARY L WAIT
70 LAUREL ST
PORT HADLOCK WA 98339
(360) 379-0978
PROJECT DESCRIPTION: DEMO EXISTING CARPORT AND DEMO EXISTING SHED AND
CONCRETE
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 8/1/2007.
REQUIRED INSPECTION:
FinalApproval: OK c4*- -king Q/i/oG ,
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
• •
SPECIAL CONDITIONS FOR CASE#BLD06-00257:
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on May 31, 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 and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property:
suburban shoreline designation; eagle; coastal SIPZ.
2.) 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 should 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.
3.) 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.
4.) 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.
5.) 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.
6.) 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.
• •
7.) 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.
8.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
9.) The applicant is proposing to create or add 403 square feet of impervious surface and
removing 270 square feet of impervious surface and 231 square feet of land disturbing
activities.
10.) 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.
11.) 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).
12.) The revised site plan dated June 29, 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 July 31, 2006 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
13.) This approval is for removal of an existing carport and existing shed and concrete slab
and a kitchen addition and new deck to a single family residence 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.
14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
15.) 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).
16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
17.) Minimum setback from Laurel Street right-of-way shall be 20 feet. Minimum side yard
setbacks shall be 5 feet. Minimum setback from shoreline top of bank is 40 feet. (Site
plan shows a setback of approximately 43 feet from edge of proposed deck to top of bank
at its closest point).
18.) 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.
19.) 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.
20.) The building height is not to exceed 35 feet.
21.) 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.
22.) The lot was created through the Portage Bay Park Subdivision on February 5, 1948 under
AFN 112767.
23.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
24.) An address of 70 Laurel Street, Port Hadlock has been assigned to the lot. Laurel Street
is a county local access road (C655409).
25.) The site is served by PUD#1 water.
26.) A septic permit(SEP93-0095)was finaled on December 2, 1994 and an EES was
conducted on August 8, 2005.
27.) Per voice message from Shelly Ament, WDFW biologist, on June 15, 2006 there is no
conflict with eagle habitat.
28.) The proposal was reviewed for consistency with the Shoreline Management Master
Program Section 3.402.5 and found to be consistent. The proposal is (1)an addition to
an existing single family residence, (2)does not exceed 35 feet in height, (3)does not
involve overwater construction and is located landward of the OHWM, (4)and meets all
required setbacks as set forth in the SMMP.
I:\F_BLD_Permit_Propane.rpt 10/29/19E
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uo/i,D/zuuti 12:04 FAX 360 491 6308 ORCAA
_ UU1 001
PERMIT#E ` a-
�»GIOX C' APPROVED / it u s
o�-� '"''`�..� CONDITIONALLY APPROVED_„„___
1
s NOT APPROVED
FOR COMPLIANCE WITH
RCAA ORCAA RE N
Notification of Demolition Permit
It is unlawful for my ��to cause or allow the
It unla ful f ris!s have bees r demolition(or major renovation)of any structure unless all asbestos-
co to ni g ni units thea owner roemoved
Corm the
are*toobtaine be demolished. Work shall not commence vn as
demolitione shalln helude a mitten approval from ORCAA asbestos project
motion that there is no known asbestos-contain• m e ainin n inaI► arcs for ea
��� �material remaining the arcs of the
Project Site Adduces. 7Q L-4Z 2 ST-
City_ _< C_� - County � r�i_`
— Date:— I _ Smote:_ GV,� 7 -
- �QO -- y ._ _._
*(There is a 10 wor>,in Cotnp�ea�n.Date: - - _ . _5 __— --
day advance notification period from receipt ofO
] permit application)
Property owner. Ai 2iGL ¢{71 e.y;�l.n}r���{jft'tisjephone: ���/}
`� 'O 3j rj
Mailing Address: �ax: G`� 73
City:
State:
�-- ziP:--�_
cJ`�e iEI �K mo -cso�
Demolition Contrietor SOS ;� f~s
Mailing Address: - u / , 0 State License#:
City; : yy� -
Contact Person: � K -fig j1 ���� Stater Zip: d�`--
Telephone: '73d (J Fax:_ c/ d /
YES NO
X _ Demolition by Wreckin or Dismantle I'' ` 1
( g �• {�25.00 fee)check#
--2 Training Fire Demolition? (If yes,attach fire department
--�- _ Renovation,Renovation,Alteration, Remodeling, request for training{'��
fig,Maintenance, or other Construction? �006
X- Asbestos found or suspected*
"An ORCAA Notice of intent to Remove or Enca sulate As ,P bestos"forrn and ° '1L
removal work Asbcstcs removal appropriate fee must be subhv��yput�bestasJ i�
projects involving demolition must be preformed by a Certified Asbestos Contractor and all friable or
potentially friable asbestos must be removed before any demolition buns. Refer to ORCAA Regulation I Article 14 for additional
requirements that may apply.
Asbestos Survey Completed by
AFIERA Certified Inspector —�.(:-_ (,� .jer,
Certification ILL. /rl D7� —e �J -/ Z-- O S -- d&-
EThis approved pore it must Enclose$25
Certification of the Asbestos Survey must
e available at the job site
Processing Fee
accompa -form ,
294013 Limited Lane NW,Olympia,Washington 98502
360-586-1044 * 800.422-5623 * fax 360-491-6308
Cf�PM'
PA llctmepage: w,vncaa org * email' infc)(a_L a_ ors RECEIVED
�.D
4
DATA ' ' JUN 5 2006
• ��� oN coA� JEFFE•N COUNTY IIIDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
• 360/379-4450 • 360/379-4451 Fax
gS, N00" www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: OL a'4
Project Description(include separate sheets as necessary):
i'l t-tV SiA/6%1-- r l i f'�S/i2 A.,,.46 ,4p 2 , / )
L ;ice, �iV C,A�'�/rt=� �%�Cf�E,�C.
Property /fv 980 T'f P 1�5 4
Tax Parcel Number: 9�--/�.--.(�/ Size:
_ SQ* (acres/square feet)
Site Address and/or Directions to Property: 70 LAviet 577 a0/2T 4/4D1,OC_ < ftf/-4 98339
Property Owner(s)of Record: P47',e&ce 0 /n,¢,Q;y, ,[, /se- 10V,,4/i
Telephone: NO-?j�j 4990 Fax: 300_379-69rT8 email:
Mailing Address: 70 L,41J. 't- 57 PQ,L 7" AJ I IA/A- • 96;3 9
Applicant/Agent(if different from owner): 7;74//n1 f y4 1--/A L(;/re, A--)
Telephone: ''2✓ - ZO2 5 Fax: - email:Y la/l/ �) v G/[ rGi US1>F ..1
Mailing Address: EC. e''X & ? t J
What kind of Permit?(Check each box that applies)
['Building ❑Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj**
kf Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home El Boundary Line Adjustment
0 Modular 0 Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use 0 Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
C/Propane 0 Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
0 Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* i i\� ?Ip Shoreline Management Variance
❑ Temporary Use `.-'0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 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 /14rn �� ' to act as
/ / /l0 . e , agent in matters relating
�—�l �Iv my 9 to this application for permit
(s).
PP P (s)•
OWNER SIGNATURE PwL 4,140'
Date: -S-?a:){o
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 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: /�i, C -Z, f���- �`
�"`"�.L _ Date: -! � G
'
> (e'
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit
has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)
even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-
transferable responsibility for adhering to and ompl ing with the ESA. The Applicant has read this disclaimer and signs and dates it below.
a
Signature: ,-��Z - -- ,z,. Date: /`-)-- G'CE
% C.
".
G:\PermitCenter\FORMS\DAD FORMS\Master Permit Application 12-30-05.doc
.¢,50N CO
k4. JEFFER•COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
�' ` ` 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
4q�, N�20� www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: 0 - -14
Project Description (include separate sheets as necessary): gem('c cx(50 4:4, C, CFt,er
' Xe/iIG V £XSr 1ic-'& '›f167.---' C0ruC-•
/� Property
Tax Parcel Number: "/ �. /00 C%`C� Size: j(�', qc'0 (acres/square feet)
Site Address and/or Directions to Property: %`C 7l_i I Gitti 6,(_- `;;I-
Property Owner(s)of Record: Pr3 i a''IG(G- <4- it44-`-.-- C-C UISC= 4 t ?—
Telephone: -3( 0 167 1q.0 Fax: ��,0 - 7�i C'7 7 f3 email:
Mailing Address: `7r) ( k '< -- S.1 PAP T /1417L 0 C- 1 G�;rq- �j , 3 c
Applicant/Agent(if different from owner): ��
Telephone: �%
P � 2C� 'Z Fax: email: �'lca �rli dVt � <" I wt ;j ti-
Mailing Address: rt.), f5/�X' Lv '2 '3 f
What kind of Permit?(Check each box that applies)
0 Building Li Variance (Minor,Major or Reasonable Economic Use)
e'Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj**
0 Single Family ,� T _V ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached 1\ 'Ili; 1', 1 ❑ Special Use(Essential Public Facilities)*"
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* Y'F F/,' r .❑ Binding Site Plan**
❑ Change of Use 1 ❑ Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane [[ ❑ Plat Vacation/Alteration**
❑Allowed"Yes" Use Consistency Analysis ail L;i,.; 'V v ; ki i' ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance
❑ Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 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:
�J DESIGNATION OF AGENT
I hereby designate I 1kr 4 I- > "u NCO A ; to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE -) A ( I A C H t_ 2 Date: 5 I ��`
0 cc
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 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. j ; ,
Signature: �' -6' vti /l`f �i�� -v� 5 /r
'Date: / 7 (�6
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 response ility for adhering to and c lyin .with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: / �f!�-�— 2 tl, ` ., .., Date: a `/j •-0 Le.
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
• 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: ex: -c.-t�- �'''7��w Date: ��
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GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
Tar ; ( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: --p owl- gr +/A.LLi ti k) PHONE (?��C ) 1jE j Z(aZS FAX:( )
MAILING ADDRESS: -p . 0 86'/? ;2- %, - 6- EMAIL ',la(( <10-1,f ) " w Vtk 7ii c ., ' -4
Project Type: L / Frame Type: Bathrooms: Shoreline: Type-bf Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank Height: 0 Community System
❑ Alteration/Remodel ❑ Concrete Total: 401 ❑ Individual System
[] Repair ❑ Masonry SEP Permit#
El Demolition ❑ Other: Bedrooms: Water Supply:
Existing: _ Setback: ❑ Private well ri Two Party
Type of Heat: Proposed: 0 Public
Total: —Z.— 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:
LI Underground Tank ❑ Above ground Tank Size of Propane Tank:
❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank 0 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 Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review:
2"°Floor Heated Consistency Review:
Other Heated Base fee:
51. 0 0
Mezzanine -� f Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: Lk.. 50
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
55 .Goa
Decks 911/Rd Approach fee:
Other TOTAL: $ c5 , 0
Receipt Number: \'"1
Cash/Check Number: 11
1 1`O
ESTIMATED COST(REQUIRED) Date: C i
.Fair market value of all labor and materials foundation to finish ,) \ ) ( (AO
Initials:
Gil)
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc