HomeMy WebLinkAboutBLD2006-00557 • -
06
b!ILDING PERMIT APPLICATION MRL Review Ty
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ype
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00557 Received Date: 10/2/2006
SITE ADDRESS: 624 LARSON LAKE RD
CHIMACUM, 98325
OWNER: MICHAEL D WARREN PHONE: 360-732-7487
LISA MARIE WARREN
101 FERN WAY
CHIMACUM WA 983258744 MT TOWNSEND VISTA
SUBDIVISION: Block: Lot: 5+
PARCEL NUMBER: 801105005 Section: 10 Township: 28 N Range: 01 W
CONTRACTOR: WARREN ENTERPRISES PHONE: (360)732-7487
PO BOX 626
CHIMACUM WA 98325
Contractor's License WARREE*947BR Expires 1/19/2008
REPRESENTATIVE: HENRY M SOUZA PHONE:
DESIGNS BY SOUZA INC
164 SWANSON -Po-rt
fkAA-k
PROJECT DESCRIPTIOP NSFR W/ATT GARAGE R€.9ti'a' ` �113(D 11' tihrt
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we.7o isItcqu i Ali "AA) 1p LCc'k 'l`a 241j01
TYPE OF WORK RES SRUARE FOOTAGE: ,
TYPE OF IMP NEW S41 ?I' tt ► f
VALUATION 275,000.00 i2Allt MAIN: 1,560
CODE EDITION: 2003 ADD'L: 859ta51 HEAT TYPE: EEE
OCCUPANCY: R-3
HEAT BASE: 3 HEAT TYPE:
OCCUPANCY: UNHEATED: 969-I(s) # OF STORIES:
OTHER:
CONST TYPE: 5N SHORELINE:
GARAGE: 544 16
CONST TYPE: SETBACK:
DECK: 1,000 BANK HEIGHT:
Via
SEWAGE DISPOSAL: ALT .../C0
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 3
Total: 3 Total: 3
Routing D te:
10r'
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,973.75 LYK 10/02/06 85054
Plan Check $1,282.94 LYK 10/02/06 85054
State Building Code $4.50 LYK 10/02/06 85054 efT 2006
Potable Water Application $55.00 LYK 10/02/06 85054
Total: $3,316.19
• •
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
PERMIT #: BLD06-00557
SITE ADDRESS: 624 LARSON LAKE RD Issue Date: 10/30/2006
CHIMACUM, 98325 Final Date: 12/18/2008
APPLICANT: MICHAEL D WARREN PHONE: 360-732-7487
LISA MARIE WARREN
101 FERN WAY
CHIMACUM WA 983258744
SUBDIVISION: MT TOWNSEND VISTA Block: Lot: 5+
PARCEL NUMBER: 801105005 Section: 10 Township: 28 N Range: 01 W
PROJECT DESCRIPTION: NSFR W/ ATT GARAGE
ADD 20 SQ FT OF DECK
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 o
��-�--
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON
12/18/2008
I:\F_BLD_Occupancy.rpt 10/29/19
• I
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00557 Received Date 10/2/2006
SITE ADDRESS: 624 LARSON LAKE RD Issue Date 10/30/2006
CHIMACUM, 98325
APPLICANT: MICHAEL D WARREN PHONE: 360-732-7487
LISA MARIE WARREN
101 FERN WAY
CHIMACUM WA 983258744
SUBDIVISION: MT TOWNSEND VISTA Block: Lot: 5+
PARCEL NUMBER: 801105005 Section: 10 Township: 28 N Range: 01 W
CONTRACTOR: WARREN ENTERPRISES 10t,2 - -11`\. °� PHONE: (360)732-7487
PO BOX 626 (��
CHIMACUM WA 98325
Contractor's License: WARREE*947BR Expires: 1/19/2008
PROJECT DESCRIPTION: NSFR W/ATT GARAGE LAI lb w (2,1 1G d rj� fk JD AZ 1X( _
CALL IN FOR THE REQUIR INSPECTIONS THAT APPLY TO YOUR PRO J CT.,
SETBACKS:
UFFER: busTALL-ED -1
Footing: fjg_ 6s/410 - 'p
Foundation: w Sj b� 7-1 -c 7 LA
Stormwater FINAL Approval:
_
/_, Uming: � GI/4oT
(•�' �1 Undergroundnderground Insulation:Plub RiMEfE� /i )5,j ,,I) e)e__ ¢,d7
Shear Wall : NiktL1 A►a2 2-t'1-'-
Sheathing:
Framing: MkCIIAOICAL Ok A' �s e's FizAMa,t 6!L B/B '
Plumbing: SEccee 0/25.7 S o
9 �i>v; k 7 8 U/Q?gR-�K 0/45#/
Propane Tank/ Lines: /i n' PieoP 1./AJ& P/8/68 i
Insulation: ,/C.. SFAL D& 8/6/6* �¢,� //
Sheetrock: �/c ��nn,l/i��o ��paA € L Pj p� b saL eae)) ore�
Septic Sytem Final Approval MUST be dbtained before final of structure can b attemd.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: ? C co CrejloA
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 CASE # BLD06-00557
1.) 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.
2.) The identified Fish and Wildlife Habitat Area (Type 5 Stream), shall maintain a vegetative
buffer setback of 50 feet. The setback shall be measured horizontally from the Ordinary
High Water Mark (OHWM) to the proposed single family residence.
3.) An additional setback of five (5) feet is required from the edge of the stream buffer area to
the proposed single family residence.
4.) A permanent physical separation along the boundary of the stream buffer area shall be
installed and permanently maintained. Such separation can include installing logs, trees,
a hedgerow, or any other prominent physical marking approved by the UDC Administrator.
5.) Stream buffer perimeters shall be marked with temporary signs at an interval of one per
parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to
and during construction activities. The signs shall contain the following statement: "Buffer
- Do Not Remove or Alter Existing Vegetation."
6.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements#1 through #12 of the Department of Ecology's Stormwater Management
Manual for Western Washington 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.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
8.) Not more than 2 unlicensed vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor
vehicles is prohibited except in those districts where specified as an autormobile wrecking
yard or junk (or salvage) yard and allowed as a permitted use in Table 3-1 or Chapter
18.18 JCC, and such storage shall meet the requriements of JCC 18.20.100, Automobile
wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor
vehicles be stored in a critical area.
9.) Minimum setback from Larson Lake road right-of-way shall be 20 feet. Minimum side and
rear yard setbacks shall be 5 feet. If an ESA is present, then the more stricter setback(s)
shall apply.
10.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
11.) 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.
12.) The building height is not to exceed 35 feet.
13.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
14.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
15.) The applicant shall adhere to the conditions as set forth in the HPA issued on March 3,
2006 by WDFW. Said permit expires on October 30, 2006.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
•
rk JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
jibtt,. 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
/s8 � ° http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# _ Q _5q3 PROJECT/APPLICANT NAME: ±1t Y y"=� .yJ r� tom, .C� b
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.
01 l litL (11 -Cis ire' f)i iii
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
4. Describe the existing soils. Indicate soil type on the site map.
5/41- /) LiI�l14l 6.41(,'(-34_9
5. Describe the existing site hydrology(i.e., drainage; behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable, and indicate acreage of each.
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6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED
.,Y[ c i:'� i? 3ZL l ' ' ✓2i 'l i> e'
t 3 � "� Tn A�t�x�e•r>�o CLAN
OCT 1 7 2006
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stormwater site plan template doc—rev 10/12/2003 JEFFERSON ' NT \
Require DE PT.OF C�a^� Tt NEL P ENT\ 5
SIGNATURE:
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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 the 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.).
` vi2- l,11-5 9 >' -1 L ., ),
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 w be fully disperse .(i.e., per BMP T5.30
in the Manual) or, if not,what types of stormwater flow control will be utilized for the siteorscre-cifinireshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities 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. Describe the performance goals and standards applicable to the project.
1
12. Describe the flow control system.
stormwater site plan template.doc—rev.10/12/2003 6
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13. Describe the water quality system.
14. Describe the conveyance system analysis and design.
/4(4
15. Describe the source of fill material, physical characteristics of fill material, and deposition of excess material.
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 of the site.
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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.)
21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here.
stormwater site plan template.doc—rev.10/12/2003 7
• •
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I—CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits.
2. Establish Construction Access.
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3. Control Flow Rates.
4. Install Sediment Controls.
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5. Stabilize Soils.
6. Protect Slopes.
7. Protect Drain Inlets.
stormwater site plan template.dos—rev.10/12/2003 8
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•
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
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11. Maintain Best Management Practices(BMPs).
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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)).
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards))„, �r
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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stormwater site plan template.doc—rev.10/12/2003 9
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• •
b. Description of special requirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g., erodibility, settleability, permeability, depth,texture, soil structure). •
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5. Construction Phasing.
a. Construction sequence�;
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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).
Provide a proposed construction schedule..
`_ `!,j�7 tzitf4 L. /,fl � �<N11
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
/7 l^
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. J
b. Diversions. `�fll/7
c. Waterways.
d. Runoff/Stormwater Detention Calculations
stormwater site plan template doc-rev.10/12/2003 10
• •
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
owne of the affected property.
N OWNE R AUTHORIZED I RESENTATIVESIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
PERM1n # BLD
O6 - 0557
JEFFERSON COONTY BC►E
stormwater site plan template.doc—rev.10/12/2003 12
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G JEFFERSON COUNTY
o- DEPARTMENT OF COMMUNITY DEVELOPMENT
' 621 Sheridan Street• Port Townsend •Washington 98368
41 0" 360/379-4450• 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
�3IN0
Master Permit Application MLA: (9(0 "5
4_5
Project Description(include separate sheet as ne ssary):n •
v.)), ir er5i cle-nts --V) ail 07c3J‘ Axil-
-t...3-I-n
Tax Parcel Property 7
4, 91)
Number. 01- I 0 �5 —0 4 5 Size: (acres/square feet)
Site Address and/or Directions to Property:
� tdY:
Property Owner(s)of Record: j f (' a,, �/j�� � �� ( �'
Telephone: I 3 4-7({t,7 / Fax: email:
v.
Mailing Address: d li i 1=t y ) ( e�(k.Z f Cr1,471 r c_,i_ n L,L - ' GI 5�3,25
Applicant/Agent(if different from owner): d ,c5 F 0 tc-/LE-.'?
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies) 1,.= j �_"� �
Building Li Variance(Minor,Major or Reasonable Economic Use)
_; Demolition Permit ❑ Conditional Use[C(a),C(d),or CI**
,?(Single Fa ' ❑ Discretionary"D"or Unnamed Use Classificatiorh /} ,"" � r�
$ Garag= Attach-•/Detached 0 Special Use(Essential Public Facilities)** Mara 6 0 ,�"3ld
Manufa.ur-. Home ❑ Boundary Line Adjustment
I Modular ❑ Short Plat**
n Commercial* ❑ Binding Site Plan** .
I Change of Use ❑ Long Plat** ' ,( N '-
❑ Address i Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments'* l
Propane ❑ Plat Vacation/Alteration**
C Allowed"Yes"Use Consistency Analysis I Shoreline Master Program Exemption/Permit Revisions**
Stormwater Management Li Shoreline Management Substantial Development**
Site Plan Approval Advance Determination(SPAAD)* U Shoreline Management Variance
- Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
I. 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 ,�coth 1 cal,state or federal permits required for this proposal, if known:
17 R 4 6f) I'I Lf ty) Ti->< CCInala v P.)VP-1(
- i '/ , �y j { IGNATION OF AGENT DOA O ?y��,,;/J Y��. S_ /A
" I hereby designate.. . ' `/ cJ to act as my agent ifi Matters relating to thiyapp on for permit(s).
• /� �
OWNER SIGNATURE / el '4//i
"t Date: q/ 2 L j“
;ii1!^ 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 knowledhe. Any material falsehood or any omission of a materiel faatmadt by the owner/agent with respect to this application packet
may result in this permit being null and void. ,
-'► I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments:court costs,reasonable attomey's fees and
' expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access,and right of o Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any re uire lat ipipe on Aos and right of entry o this property shall ke requested and shall occu only du ng regular business
hours. �-/` r// , / /` t�-!��
Signature: �/ a./ •- a raid rki-- Date: / �Z
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 s cies as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurancesjo 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 yqujre in complian ith'the Jefferson Co ty development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable pen i6itity r adherin rid co lyi g w' the ESA. The Applicant has read this di lai sr and • nssaa dates it below.
Signaturef /, / �� .�1 i/ / �' Date: !_ jJ-
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc
110 10
OWNER BUILDER STATEMENT — A 44 i"i c N. / ') CT-, C
l ,
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
t.ti c4 a- Ek .N ( fi? Ls -S ( .C.. ) cf E' L-`i 3b i ( 3�v) J,)Z-.}71 )
MAILING ADDRESS: ‘,./.( .. c) < L ; (�
( .I 1 kK l _ EMAIL: L a ,E 1 �1 L/1,_pefl .
can
CONTRACTOR'S LICENSE WAINS
NUMBER: l NUMBER
ARCHITECT/ENGINEER: ej.�{ �4i1.e 7 �, 1'h1 ) Lx-J i G•A(PHONE ( ' ,() 3 79 C'3 C.( )
MAILING ADDRESS: I 1-1 c• '(Aat.,,WV _ 'vj, t�VC. cr' EMAIL 1,1•r'y ft ( e`)`
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New lg" Wood Existing: ❑ Sewer
Addition ❑ Steel Proposed: 4 _ Bank ❑ Community System
Alteration/Remodel ❑ Concrete Total: 3 - Hei' (Individual System
Repair ❑ Masonry A Si SEP Permit# ,S ilt10"Ott X
Bedrooms: Water Supply:
Demolition ❑ Other: PP Y:
Existing: Sets ack: ' Private well Two Party
Type of Heat: Proposed: A ❑ Public
Total: 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 co tructi n: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance In Ila on ermit mark a items below that apply:
i Underground Tank I Above ground Tank of Pr ane Tank:
i Heat Stove i Cook Stove i Woodstove i Fi pla Inse I Hot ater Tanr"i-Peffet Stove i Other
Is this appliance being installed in a Man actu d/ obit ome? Yes / No
When applying for a permit to install a propane tan 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. I
Square Footage For Office Use Only i 3/_
Current Proposed C25� 1P
Main Floor t' 13efZZ.S1D Consistency Review. N .
2""Floor 1.9`( ''It,99Z•1'I' !Base fee:
\z 1c(lerl ipD,DO Q iC (`-193• riP" "1
3m Floor * i 5�ant Additional Section: II
a i t�tlo-1 15a `5�
Mezzanine: ��t^Q�2p Plan Check fee '"S ,� io'aL 1So�.� ��C 91
OW tG,20 t tUk DO r Q
Heated Basement- '7S40 a a�( tare Surcharge fee: •50
t
Unheated Basement j fdS Pot Water Review fee: -lO
Other Unheated ,-t- `6 1to60.45" 911/Rd Approach fee:
Garage/Carport / 12$T1.0$ K¢J���ob k -\kCIlq E�C�STI
(� �i TOTAL: $ vAe,2o ` 51 (J�
Decks L-Z Ot tt• r r d-JO c�jj ���"1
torY1•{ >e.' �- �)9,6U a3 Receipt Numl�e . Bso q1i '
Other - �1100/ ash/Check Number: u
/ °( . 12(02 i3�- �A49
ESTIMATED COST(RE a • a — Date:
.Fair market value of;owe.• .n. foun.a/.� � 1� '
a" l j ODO Ind
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Inc WARREN RESIDENCE
+� '••^�Y• Lot#5 Larson Lakew Road