HomeMy WebLinkAboutBLD2006-00318 •
PJILDING PERMIT APPLICATTN MLA06-00298 Review
Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00318 Received Date: 6/7/2006
SITE ADDRESS: 680 OLYMPUS BLVD
PORT LUDLOW, 98365
OWNER: TRACY L SEIBER PHONE: 206-619-2446
619 SW 122ND ST
SEATTLE WA 981462848
OLYMPUS BEACH
SUBDIVISION: Block: Lot: 2
PARCEL NUMBER: 978900115 Section: 4 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI NSFR W/ ATT GARAGE &A/G 500 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,325
VALUATION 233,706.00 ADD'L: 914 HEAT TYPE: RAD
CODE EDITION: 2003 HEAT BASE: 1,131 HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N SHORELINE:
GARAGE: 570
CONST TYPE: DECK: 401 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 4
Total: 2 Total: 4
Routing Date:
Type Amount Paid Bv: Date: Receipt: A Approved/Date
Permit $1,744.15 LYK 06/07/06 83506
Plan Check $1,133.70 LYK 06/07/06 83506 JUN a32006
State Building Code $4.50 LYK 06/07/06 83506 Jefferson County Planning
Potable Water Application $55.00 LYK 06/07/06 83506 & Building Department
Total: $2,937.35 n
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BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00318 Received Date 06/7/2006
SITE ADDRESS: 680 OLYMPUS BLVD Issue Date 06/23/2006
PORT LUDLOW, 98365
APPLICANT: TRACY L SEIBER PHONE: 206-619-2446
619 SW 122ND ST
SEATTLE WA 981462848
SUBDIVISION: OLYMPUS BEACH Block: Lot: 2+
PARCEL NUMBER: 978900115 Section: 4 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NSFR W/ATT GARAGE &A/G 500 GAL PROP TANK
CALL IN FOR THE REQUIRED I SPEPTIONS THAT APPLY TO YOUR PROJECT. t
SETBACKS: OK/.dfil
CGI/di JD�j (ReetIteg Q �»/.cAUDArfoL) RA.5/o t p 1'�
UFFER: ()l� f3�25�6,G I. n A
air
Footing: 0 / $79
Foundation:0-ro Ftsu,E Or YDIi.e otva.) Ras K eeirsi,ma ):riut.tel EesIG READ ryaJ2 Escr'RA t I'at-rop aF&mu.
Stormwater FINAL Approval: 44 4hawA d1C1412106�
Underground Plumbing: OK�IZ/OVA �Aw QED'�
Underground Insulation: Dy( /D ro Au..ivrkritzSND1PUALLSP�EK Wel— 's-SO
Shear Wall : t�trkc,a,� c'K 5:/c? / !'-r 5i�-c /t-- rL.-tt,,-ti'. Ce , =1 1:1-DSI,De-/N ,
v �y
Sheathing: ::nr:Ac- _ / JfIn�/,-Z OC rr
Framing: AK-no 6uesir J ,a,;or G/aw 9A%1� l (� ? )
Plumbing: ./YtYROAJkC ZWES l) /O/DA, LeMBILTG 6k G/�07 �il010(+fltt14l.(, bl/w1I �� �,
Propane Tank/ Lines: /NT Jlu�s Dk t3rzefr i t L,-LaM 01(S-TA7d?.(1/
- -- (.,' 7-c8
Insulation: A \;J. _SS; 7-07
Sheetrock: (,DR dk 4/io/67 �U C
Septic Sytem Final Approval M S bened befor -f nal of structure can be atte ted.
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 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 CAtit BLD06-00318 •
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 nct 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 Water 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 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).
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.) Minimum setback from Olympus Boulevard right-of-way shall be 20 feet. Minimum side
yard setbacks shall be 5 feet. Minimum shoreline setback shall be 30 feet from ordinary
high water mark if bank is less than 10 feet in height. If bank is 10 feet or higher in height,
then the minimum setback of 30 feet shall be measured form top of bank. Site plan dated
June 7, 2006 identifies a 97 foot setback from OHWM.
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.) The building height is not to exceed 35 feet.
15.) 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.
16.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
I:\F_BLD_Permit_Buildng.rpt 10/29/1999
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.�ozc6 JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
��,., 621 Sheridan Street • Port Townsend •Washington 98368
•�� -0/ 360/379-4450 • 360/379-4451 Fax
"�1N http://www.co.jefferson.wa.us/commclevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# ao - 9CEPROJECT/APPLICANT NAME: S L t L P.,- r2,F-S 1 C.e
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.
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Existing Conditions Summary
2. Describe the existing topo raphy.. Indicate contours on the site map
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3. Describe the existing vegetation. Indicate/native vegetation areas pn the site map.
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4. Describe t e existing soils. Indicate soil type on the site map.
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5. Describe the existing site hydrology(i.e., drainage; behavior of water on the site—above, below, and on theground). 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 r
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6. Describe any excess levels of noise generated by the proposed use or activity: STOR v1 WATER PLAN
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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 pth"e site map. /
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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.).
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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 facilities frrm exiting 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 potentjal for plispersion of contamin ts.] _-J
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11. Describe the perfortna ce goa s an standalds applicable to the elect.
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12. Describe the flow control system:
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13. Describe the water quality system.
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14. Describe th nveyance system analysis and design.- p
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15. Describe the source of fill material,physical characteristics of ill rr7tX:4It,3rbid depositjpn 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 C
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17. Describe the proposed surfacing material. (� o
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18. D scribe methods for restoration of the s' . 1
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19. An Operation and Maintehance 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. J 1 ,
20. List here and include y special reportsstudies coiticte jo prepare the ormwate[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. i/u,,
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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.
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2. Est b ish Constru Lion Access.
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Controlflow Rates.
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4. InI k Sedimoent Coptrols. ,, L �4, 5-,�j_ t J_
5. Stabilize Soils
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6. Protect Slop $.
7. Protect Drain Inlets.
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stormwater site plan template—rev.10/1/2003
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12 Required Elements-Construction SWPPP(continued) J j N - 7 2006 i
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8. Stabilize Channels and Outlets. i
9. Control Pollutants.
10. Control De-Watering(tl act pumping groundwater or sto water away from an active construction site).
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11. Maintain Best ianagement Practic (B Ps).
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a 12. Manage the Project.
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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). �#}'�LT�(, y� J� J][�.ry7 /� i / 4:;‘),
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3. Environmentally Sensitive Areas.
a. Description of envirp ntallysensitive areas that ate on or adjacent to the site.
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stormwater site plan template—rev.10/1/2003
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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
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provi eya proposed constructio chedul .
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II. Wet Season Construction Activ ies.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.a. Identify the prope y owner respo ibl for the initiation band o' r other financial securities.
.1 --c.,
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
stormwater site plan template—rev.10/1/2003 10
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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 affect prpperty.
r
( DOWNER OR AU HORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
stormwater site plan template—rev.10/1/2003 12
rik6,
¢g cJEFFERs COUNTY •
DEPARTMENT OF COMMUNITY DEVIELOPMENT
4
621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax w`, — �
ryS,4trI NOO www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: CIO'a cis
Project Description (include separate sheets as necessary): 5jO C (LI t ii IA_
►F IQ. [�7 I�-. cd"h--c1�-k j c qJ' e c z'v e. 1 r o A 1. p e a-!� -+a L_
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Tax Parcel Number: 1 �- c� Cad roS ie: 3 / 7 (acres/�uare feel)
Site Address and/or Directions to P erty: (o 0 OIA 1r1�0 ,,�,5 Qi V k , P I----- L d 1� I �� `�-3i,
Prop rt O ner(s)of Record: I V Ck Ct,] 1- i t rt n c_I 3
ono e':I' oL [G-...1- j`-}-b �l Fax:l ° L•Telep one: � J'`"1-4'-q Ci'S'S— email:
Mailing Address: jv[ /.A;)-"`� S
Cl( 1. r"rc}- Set&41-1 e/ W -
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
X.-Building ❑Variance(Minor, Major or Reasonable Economic Use)
[l Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
)Single Famil ❑ Discretionary"D"or Unnamed Use Classification
1-Garage ache Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address i] Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
'RC-Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment
0 Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate 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 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.Acce s and right of entry to this property shall be requested and shall occur only during regular business
hours. /
Signature: �`' Date: 613 G/G�
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 sponsibility for Gering to nd c ying with the ESA. The Applicant has read this disclaimer arit s nns andjdatep it below.
Signature: p
�� Date: 2G
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
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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 as uming the resp nsi ity of th Gene
Ly I Contractor for the proposed project.
Signature: it--et Date: S /3 0 / 0
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
MAILING ADDRESS: . i >` ., J f EMAIL:
CONTRACTOR'S LICENSE •_ WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
.New —Wood Existing: 0 0 Sewer
❑ Addition ❑ Steel Proposed: + Bank Height: Il Community System
❑ Alteration/Remodel ❑ Concrete Total: y individual System
❑ Repair ❑ Masonry SEP Permit# Og a--1
❑ Demolition ❑ Other: Bedrooms: 0
Water Supply:
Existing: Setback: LI Private well Cl Two Party
Type of Heat: Proposed: "4'Public
r`L rki� \ Total: �, See, Name of System: C9/ m p uS
-)1 1-e-, gcCYCLi / I,---Ci
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 agdy:
I 1 Underground Tank KAbove ground Tank Size of Propane Tank: I -a j 1 t`1'L,
I] Heat Stove Cook Stove I 1 Woodstove Fireplace Insert 0 Hot Wetpr Tank a Pellet Ste ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes i
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
x. Main Floor Heated - I IS .-S EH Bld App Review: 00
Y 2 Floor Heated q 14 T 19Z 1 . ..2 Consistency Review: 153 (-'
Other Heated I Base fee: ��
n
Mezzanine ,` Additional Section: __._______
k Heated Basement x` I Dl3^► 5 3 Plan Check fee:
J ( 3 1 1133. 170
Unheated Basement State Surcharge fee: 50
Other Unheated12r Pot Water Review fee: clr_`�J
Garage/Carport 7 i) V1st.,SU.rio SUBTOTAL
31C10 .35
Decks. ^ QplSt.51 911/Rd Approach fee:
tiV .e-t-j ►fzv 9 01 l stl
TITAL: $ 8)00 5
d ZW�Receipt Number:
Cash/Check Number:
510 at 4 ---
-EpTIMAT COST(REQUIRED) 3370b Date:
:Fair market value of all labor and materials foundation to finish (L) 16 ( ,y atO
Initials:
V L v e
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