HomeMy WebLinkAboutBLD2006-00613 • BUILDING PERMIT •
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00613 Received Date 10/24/2006
SITE ADDRESS: 6655 THORN DYKE RD Issue Date 11/27/2006
QUILCENE, 98376
APPLICANT: JON R SMAKER TRUSTEE PHONE: 925-963-9920
KIM VOGLEY TRUSTEE
PO BOX 65485
PORT LUDLOW WA 98365
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 701253005 Section: 25 Township: 27 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW GARAGE - NO HEAT, NO PLUMBING
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: "7
UFFER:
Footing: Q/ 7/2�0 EA:riasc ..1-21¢AIv isJsrALLED 6/zofo7
Foundation: Die 1 /,I �'y ,4 N&,R &ss 4Pi�rr D 9/14/47
Stormwater FINAL Approval: �v G�/erOpc/E /,vi'rALL $ 00 o7 /�'
Underground Plumbing: a Ft c DR&,ps o� R/� ,v
Underground Insulation: DK Q,'/10?�
Shear Wall : OK taps/a
Sheathing: 0/ /n,?507
Framing: 6e 72.107 ','
Plumbing:
Propane Tank/ Lines: IU/A
Insulation: JSk 4/A as 4 CE-cum /05767#
Sheetrock: /�/,q
Septic Sytem Fi al Approval MUST be obtained before final of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval: nn
Final/Occupancy Approval: OK Pei, 1,'ill.i .5r/3D/'8 A/
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 CAS•BLD06-00613 •
1.) A vegetative buffer of 30-feet 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.
2.) A Geotechnical Report dated June 19, 2006 prepred by Stratum Group was submitted in
conjunction with this application. The report addressed the stability of the geologic hazard
area. A setback of 40-feet shall be measured perpendicularly from the top edge of the
steep upland slope for the proposed single family residence. Septic drainfield shall be
located at least 50 feet from the top of the bluff.
3.) 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.
4.) 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."
5.) All construction activities shall not encroach upon the landslide hazard area buffer. This
includes the storage or preparation of materials.
6.) 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.
7.) 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.
8.) 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.
9.) 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.
10.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
12.) 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.
II
13.) Minimum setback from Thorndyke Road right-of-way shall be 20 feet. Minimum north
property line (commercial forest lands adjacent) shall be 100 feet. Minimum south
property line setback shall be 5 feet. Minimum setback from top of bank as shown on site
plan is 300 feet.
14.) 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.
15.) 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.
16.) 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.
17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
18.) The building height is not to exceed 35 feet.
19.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat
management plan signed by the proponents and WDFW on August 11, 2006.
20.) 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.
21.) 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.
22.) 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.
I:\F_BLD_Permit_Buildng.rpt 10/29/1999
GILDING PERMIT APPLICATV MLA06-00594Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00613 Received Date: 10/24/2006
SITE ADDRESS: 6655 THORNDYKE RD
QUILCENE, 98376
OWNER: JON R SMAKER TRUSTEE PHONE: 925-963-9920
KIM VOGLEY TRUSTEE
PO BOX 971
RENO NV 89504
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 701253005 Section: 25 Township: 27 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr NEW GARAGE - NO HEAT, NO PLUMBING
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 55,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: 2,064 SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 0 Prop: 0
Total: 0 Total: 0
Routing Date: I peef fo
Type Amount Paid By: Date: Receipt: Approved/Date
' Permit $678.75 CJZ 10/24/06 85256
Plan Check $441.19 CJZ 10/24/06 85256 NOV a12006
State Building Code $4.50 CJZ 10/24/06 85256
Total: $1,124.44
• • •
g"Sozv c4�
eN, JEFFERSON COUNTY
4410. 1 DEPARTMENT OF COMMUNITY DEVELOPMENT
E ,y 621 Sheridan Street • Port Townsend • Washington 98368
A,O 360/379-4450 . 360/379-4451 Fax
NO http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# PROJECT/APPLICANT NAME: JfrAL>. e i/". SR.
QI G-0,1/4,v- 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 4--m�map. 1 ue:.t`
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Existing Conditions Summary
2. Describe the existing topo{graph�y. Indicate contourson the site map. ( 1
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3. Describe the existing�l vt-cjgetation. Indicate native-vegetation"areas o!n the isite map. ) } i f
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4. Describe the 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 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 a ch.
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6. Describe any excess levels of noise generated by the proposed use or activity: Ar PROVED
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NOV 2 2 2006
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
stee�p,,//slopes,,etc.)o the site. Indicate
' iilocatio n the site./map.
8. Describe the general vicinity of the site,including adjacent land uses and structures, utilities, roads, and sensitive/critical areas
(streams,well nds,lake],steepolopes,etj/)�f �i
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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
withiy the site. Locate these facilities on the,site plan and d' erentiat proposed faciliti s from existing facilities.
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 a s and sta dards applicable to the project.
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12. Describe the flow control system. t Li rel.%arl- CA VrVi ,-.11‘fs y Lx
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stormwater site plan template—rev.10/1/2003 6
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13. Describe the water quality system. •
14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Buildin Code.
17. Describe the propo ed surfacing material.
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18. Describe methods for restoration of th sit
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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.
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21. List other necessary permits and approvals as required by other regula ry 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—rev.10/1/2003 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. Markk LAC.
Limits. /� • \ y- yJ�
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2. Esta fish Co struction Access. fie
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3. Qqptrol Flow Rates. f,,L11 4;tv,-v+t- w.1/4 -4,- t ii -Yu lly As p4-.' l
4. Install Sediment Controls. file;,4 yi-e t&e.( ' f1.,,,.,-Y ''"te 1'`'0"A'-e'er`'
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5. . Stabilize Soils.
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6. Protect Slopes. a_
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7. Prot ct Drain Inlets. ii i } l
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stormwater site plan template-rev.10/1/2003 8
• 411
12 Required Elements—Construction SWPPP(continued)
8. S abi ize Channels and Outlets. }
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N0. 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 j
rea that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
arroads).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). } ]
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3. Environmentally Sensitive Areas.
a. Description ef environmentally sen itive reas that are on or a{djj cent to the sit .
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stormwater site plan template-rev.10/1/2003 9
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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,91e0,texture,soil structure).
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5. Construction Phasing.
a. Construction sequence y
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b. Construction phasing(if proposed)
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed cons ruction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for enviro entally sensitive reas. -
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiatiop of bonds�/ and/or other financial securities.
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b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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8. Engineering Calculations. Provide Designcalpulations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. f f I^p
c. Waterways.
d. Runoff/Stormwater Detention Calculations / I A
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
owner of the eated pro7 .
lfl / cry-,
DOWNER OR AUTHORIZED REPRESENT VATU E) 1 (D E)
q / 111
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stormwater site plan template-rev.10/1/2003 12
0
, 9°N COS JEFFERSON COUNTY f- ` _; i
fic ' 4$44 r DEPARTMENT OF COMMUNITY DEVELOPMENT ilk
621 Sheridan Street • Port Townsend •Washington 983681 _ ^�
360/379-4450 • 360/379-4451 Fax
www.co.efferson.wa.us/commdevelopment ��� 4 ���E
q`SI1�tG� j ,
Master Permit Application _ �r
MLA: 0(0 '`)
„ -1�.,
Project Description(include separate sheets as necessary): __
-
Tax Parce(
Number: "1012- 3c,t'r Property
Size: S.C-)5 A acres quarefeet)
Site Address and/or Directions to Property: cz to� - - d tz_e
Property Owner(s)of Record:don Z. c���ai(t - i <in m ;e y
Telep t QV l i c'fC-?Y1� ��31�
ne:�Z,, S etW -ct q u� Fax: l
Mailir drelsS:��g$85 f--} U tow email: �i�n YV j�GZtr�rhlt�liL.(1�?�-
I
l�3•A 983Co S
Applicant/Agent(if different from owner): - -y- ,_
Telephone: Fax:
•Mailing Address: -- email:
What kind of Permit?(Check each box that applies)
Building
U Demolition Permit U Variance(Minor,Major or Reasonable Economic Use)
U Single Family U Conditional Use(C(a),C(d),or C1**
41
U Garage Attached/ etachecJ} U Discretionary"D"or Unnamed Use Classification
Li U Manufactured Home Special Use(Essential Public Facilities)
U Manulai U Boundary Line Adjustment
U Commercial* U Short Plat**
u Change of Use U Binding Site Plan**
U Address U Long Plat**
Road Approach U Planned Rural Residential Development(PRRD)/Amendments**
U Propane U Plat Vacation/Alteration**
L 1 Allowed"Yes"Use Consistency Analysis U Shoreline Master Program Exemption/Permit Revisions**
}T Stormwater Management U Shoreline Management Substantial Development**
u Site Plan Approval Advance Determination(SPAAD)* u Shoreline Management Variance
u Temporary Use
u Wireless Telecommunication* U Comprehensive Plan/UDC/Land Use District Map Amendment
U Jefferson County Shoreline Master Program Amendment
U 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:
I hereby designate 1-- DESIGNATION OF AGENT
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 provi e acce and t of entry 1•Jefferso County and its employees,representatives or agents for the sole purpose of application
review and any requ d later specf•ns.Acces /nd right o ntry to this property shall be requested and shall occur my duri g regular business
hours.
Signature: i joi4`..0 _e".....
Date: 0
The action -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 Specie Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been iss d will violate the ESA. y individ al,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if y are in plia ce with the erson C. my development code.The Applicant acknowledges th t he,she r it holds individual
and non-transfer le resp ibility or adherin nd comp ing wit. the ES . The Applicant has read this disclai a and si a dates it below.
Signature .i/•�� `�
%', ' Date: 0 U
C:\Documents and Settings\mochil\Desktop\Master Permit Application t'8-04.doc
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OWNER BUILDER STATEMENT
The signer of this s eme oe hereby ce . that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be asSu g the po ibility oft eneral Contractor for the proposed project.
I Date: d 6
Signature: ^,.., p
GENE CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAx:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EiviAIL
•
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
Cl Wood Existing: ❑ Sewer
D Adw Addition ❑ Bank ❑ Communit Steel Proposed: y System
Total: Height: -Individual System
O Alteration/Remodel ❑ Concrete �(^`--'' SEP Permit# cY.0 Zq-ly
❑ Repair. ❑,,/Masonry
Other:S(P Bedrooms: Water Supply:
❑ Demolition Existing: Setback: I-i Private well ❑ Two Party
Proposed: ,���}_ ❑ Public
Type of Heat: Total: C) Name of System:
If this is a Commercial Project you must answer the following:Proposed: Number of ADA Parking Spaces:
Number of Parking Spaces: Current: Pro p Proposed
Number of occupants(includes owners,tenants,employees,etc) Current Will you have Food Service? Yes / No
IBC Occupancy: IBC Type of construction:
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
i Underground Tank I Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove I Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other
Is this appliance being installed in a Manufactured I 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.
ISquare Footage For Office Use Only 11 � r_
Current Proposed l l �P
Main Floor Consistency Review: f r
2Nu Floor Base fee: / In • I��
3`d Floor
Additional Section: �O
Mezzanine: Plan Check fee: -424 1.1)‘
Heated Basement State Surcharge fee: -1 5D
Unheated Basement Pot Water Review fee: —
Other Unheated 911/Rd Approach fee: /N
Garage/Carport 2Q&4- 164g 9 q TOTAL: $ 12 Q �
Decks Receipt Number: .3, (C31
Other Cash/Check Number:
ESTIMATED COST(REQUIRED) ,----- - --------., Date: �a7/a�/a6
.Fair market value of all labor and atedals foundation to finish — l
s6`D Initials: 6)-6- _
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0 6655 Thorndyke Rd., Quilcene,
Cr)sumoll N Jefferson County, WA
v' w Parcel701253005
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