HomeMy WebLinkAboutBLD2006-00721 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 #: BLD06-00721
SITE ADDRESS: 253 N ANDREW AVE Issue Date: 01/10/2007
PORT TOWNSEND, 98368 Final Date: 9/14/2007
APPLICANT: KELLEY SHIELDS INC PHONE: 360-385-7156
260 KALA POINT DR
PORT TOWNSEND WA 983689530
SUBDIVISION: IRONDALE BLK 134 Block: 134 Lot: 1+
PARCEL NUMBER: 962113401 Section: 35 Township: 30 N Range: 01 W
PROJECT DESCRIPTION: NEW SFR /A/G 120 GAL PROPANE TANK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2003 EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes no
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 9/14/2007
Building Official Signature Date
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I:\F_BLD_Occupancy.rpt 10/29/19c
0 •
BUILDING PERMIT
Jefferson County Department of Community, Development
621 Sheridan Street, Port Townsend WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00721 Received Date 12/27/2006
SITE ADDRESS: 253 N ANDREW AVE Issue Date 01/10/2007
PORT TOWNSEND, 98368
APPLICANT: KELLEY SHIELDS INC PHONE: 360-385-7156
260 KALA POINT DR
PORT TOWNSEND WA 983689530
SUBDIVISION: IRONDALE BLK 134 Block: 134 Lot: 1-2+
PARCEL NUMBER: 962113401 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR:
PROJECT DESCRIPTION: NEW SFR/A/G 120 GAL PROPANE TANK
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS:
UFFER: 5e(---- '
Footing: RED ..s-SIAES)- 3A! D7 /yioN0 Abej Z''y,Q rn r- ifrAte4 by o,rFaori"J 7a—
Foundation:Q (-4 S1pE5 L 3/1 7 f44/"J e / w�/ ./ 6-2
Stormwater FINAL Approval: v
Underground Plumbing:
Underground Insulation:
Shear Wall : oSB [,IK C7 5 -(-(-_ Gtiba
Sheathing-
Framing: (ol- i9?
Plumbing:' c1J 6 7
Propane Tank/ Lines: L.
Insulation: 6-7--7 ` (.0 /i��/ . (y-7-O 7
SheetrocK~ f1-cr 7
Septic Sy em Final Approval MUST be obtained before final of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: /9-t 7-0 7
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 CAE# BLD06-00721 •
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 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.
3.) 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.
4.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
5.) 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.
6.) Minimum setback from North Andrew Avenue and Kala Point Drive rights-of-ways shall be
20 feet. Minimum side and rear yard setbacks shall be 5 feet.
7.) 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.
8.) 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.
9.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
10.) The building height is not to exceed 35 feet.
11.) A minimum of two on-site parking spaces shall be provided for the single family residence.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
1
BADING PERMIT APPLICATI MLA06-00682ReviewType: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #:
BLD06-00721 Received Date: 12/27/2006
SITE ADDRESS: ANDREW AVE
PORT TOWNSEND, 98368
OWNER:
KELLEY SHIELDS INC PHONE: 360-385-7156
260 KALA POINT DR
PORT TOWNSEND WA 983689530
IRONDALE BLK 134
Block: 134 Lot: 1-2+
SUBDIVISION:
PARCEL NUMBER: 962113401 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR: PHONE:
PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEW SFR I AIG 120 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 988
VALUATION 168,490.00 ADD'L: 795 HEAT TYPE: PRO
CODE EDITION: 2003 HEAT BASE: 297 HEAT TYPE: EEE
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER: SHORELINE:
CONST TYPE: GARAGE: 691 SETBACK:
CONST TYPE: DECK: BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 2 Prop: 2
Total: 2 Total: 2
Routing Date: la al 10(0 ( �
Type
Amount Paid By: Date: Receipt: Approved/Date
Permit $1,570.55 CJZ 12/26/06 86978
Plan Check $1,020.86 CJZ 12/26/06 86978
State Building Code $4.50 CJZ 12/26/06 86978 i() ;7t.:.
Potable Water Application $55.00 CJZ 12/26/06 86978
Total: $2,650.91
(7-5°N7- 0JEFFERSO OUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT , P a h1P 621 Sheridan Street• Port Townsend*Washington 98368 360/379-4450 • 360/379-4451 Faxwww.co.jefferson.wa.us/commdevelopment DEC 2 6 2006 ILL,
M Permit Application ;MLA:
Project Description(include separate sheets as necessary):
.oPmENr
s!fitLe- � µtL'•( �af
Tax Parcel Property ,
Number: 0 ‘‘a 40 Size: 1 2 t- (acres/square feet)
Site Address and/or Directions to Property: Z-I,.t 1j QF j-y.+
Property Owner(s)of Record: 14Ecu-ell 5 tit >5
Telephone: " 85- 1t'SLa . Fax: 385-' ,t•S email: I.e.
Mailing Address:Z(,O P/2.. qs 5{ to jtr4C2S • tL
Applicant/Agent(if different from owner):
Telephone: ----- Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Building J Variance(Minor,Major or Reasonable Economic Use)
U Demolition Permit J Conditional Use[C(a),C(d),or C]'*
U Single Family J Discretionary"D"or Unnamed Use Classification
U Garage Attached/Detached J Special Use(Essential Public Facilities)**
U Manufactured Home 7 Boundary Line Adjustment
U Modular J Short Plat**
U Commercial* J Binding Site Plan
U Change of Use J Long Plat*"
U Address I Road Approach J Planned Rural Residential Development(PRRD)/Amendments
,,ropane J Plat Vacation/Alteration"
U Allowed"Yes"Use Consistency Analysis J Shoreline Master Program Exemption/Permit Revisions"
U Stormwater Management J Shoreline Management Substantial Development"
U Site Plan Approval Advance Determination(SPAAD)* J Shoreline Management Variance
U Temporary Use J Comprehensive Plan/UDC/Land Use District Map Amendment
U Wireless Telecommunication* J 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:
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 fornt,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best pf
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. ccess and right of entry to this property shall be requested and shall occur only during regular business
hours. �I• / 1
Signature /!t/D^-t-. Q• V i ,/� r�// Date: l0 1�� /
�r
The actipn or actions Applicant will undertake as a result of the issuance of this permit may ne•atively impact upon one or more threatened or
ndangered 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-transfer Ibblee rre_sponsibil' for g to and comptlyin with the SA. The Applicant has read this disc imer and signs and dates it below.
Signature: - r V- y Date: L f'"S f 2-en-0 .4a
A4,� ttl
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc
OWNER 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 pro o�exl-prdJYt" " 4
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
V.el.,Let S _k 5 li^les° , (3(2Ca) ;9S-1f_SL ( 3(. ) 33s-7 L5
MAILING ADDRESS: 1(¢�p p EMAItdcw 1 e) d o b i IAA t)S e v' ,
CONTRACTOR'S LICENSE WAINS
NUMBER: tL -U.,E'SS j Got-c f NUMBER
t.r ,•'"
ARCHITECT/ENGINEER: t ' /AITr) PHONE ( ) FAX:( )
MAILING ADDRESS: 24.00 V./...Art,,pir . ;?2.f EMAIL alsA i d. c. } /Ai Feou c 4 i ..,°
I
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: +�+
New 4.L Wood Existing: l
U Sewer
U Addition U Steel Proposed: c BanlU Community System
UAlteration/Remodel U Concrete Total: 2 Heigt: U Individual System
U Repair U Masonry SEP Permit#p( -0D )eq
U Demolition U Other. Bedrooms: / Water Supply:
Existing: y`d Se ack: U Private well U Two Party
Typ of Heat: Proposed Total: ✓ U Public
Name of System: I L i2
e
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:
I Underground Tank I y ovb e ground'rann� Size of Propane Tank: ) 2Q
eat Stove I Cook Stove I V Toodstcve I Fireplace Insert I Hot Water Tank I Pellet Stove I Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying fora permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office.Use Only
Current Proposed .1{ li:- - _---
Main Floor 17;tcl Consistency Review: {
2NU Floorc1,438 I ,--, Base fee: I b 10,55
1
3ftl Floor C Additional Section. x_.-
Mezzanine: 1 Plan Check fee: "'oao' gj_
Heated Basement Z��Y' • it State Sur"charge fee: ,d .c.)
Unheated Basement ! Pot Water Review fee: co a;)
Other Unheated 911/Rd Approach fee:
Garage/Carport ` 1 `
GPI r (0, TOTAL: $ 3.055,CI i
Decks ceipt Number: e(, i 1g
Other d, /Check Number: 1 (�
0 eas
�1
ESTIMATED COST(REQUIRED) ale;-— ---
\\ 00
.Fair market value of all labor and materials founaQp tO finish _: 14, 'G
* \ A ck Q ,T Initials:,f _, .�.. —. ••• 11
if 6
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04-doc DEC 220
"
i Y
.jEVELOPMENT
• •
• JEFFERSON COUNTY � � '
Th
DEPARTMENT OF COMMUNITY DEVELOPMENT In
621 Sheridan Street• Port Townsend •Washington 98368
p 360/379-4450 • 360/379-4451 FaxDEC 2 6 LUJ
IN http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE�.LOF,,I`NT
MLA# PROJECT/APPLICANT NAME:
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 chodse 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.
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
Sc-0c •
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
` ✓ K.
4. , Describe the existing soils. Indicate soil type on the site map.
s) 4,Q 4",..•
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.
6. describe any excess levels of noise generated by the proposed use or activity:,
)•il 'A- APPROVED
STORMWATER PLAN
stormwater site plan template.doc-rev.10/t2f2003 DEC 2 9 2006 5
orate
St011 JEFF RSO t ►UN
erlUired DEPT.OF C•* L EVE E%\�
R SIGNATURE: I ,
7. Describe significant geographic features and critical areas (i.e., environmentally sensi'ive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map. �(' 7�n�� _�
t�J hJ r . .
.'c"VEL0PMENT
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.).
P 1 6 )�- L(-gip; E
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 from existing facilities.
'C>t SC�v-d+ tct S"f oCi ti`1'-T r v' ' .
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.].
11. Describe the performance goals and standards applicable to the project.
12. Describe the flow control system.
f Cr 4 <,1 V eozi o.J .
stormwater site plan template doc—rev.10/12/2003 6
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13. Describe the water quality system. / '� r
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I L'EC 2 6 `- -�
14. Describe the conveyance system analysis and design. t t V-t.U1 t1'-.
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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 Building Code.
COrii,Rc, 7o#t
17. Describe the proposed surfacing material. __ll
C eAt etil C/A/Lie/0nr.!
18. Describe methods for restoration of the site.
f&„s,ed 06 Re -fog
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. ))
N/4
20, List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
A(
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. / ;
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stormwater site plan template.doc—rev.10/12/2003 7
CONSTRUCTION STORMWATER POLLUTION PREVENTION PL F r"(i/VP3. ---f
The Construction SWPPP addresses sediment and erosion control during construction. The MPs indicated by th a nt in the I
template that follows must be installed on the ground during all construction phases of the pr ct. The pjGne2tT r4s lsibl' trail
sediment and erosion impacts to environmentally sensitive areas and off-site areas. onsult the Construction Storm`�ater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidan e, particularly with rural residential
V
development.
t EVELOP!',IENT
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.
3. Control Flow Rates.
4. Install Sediment Controls.
,s t.C, .74.- 4 4.a
5. Stabilize Soils.
\d'"\ ,
6. Protect Slopes.
SA/V,Q Le,“4 lA GML/11.4
7. Protect Drain Inlets.
stonnwater site plan terhplate.doc—rev.10/12/2003 8
4111 All
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
JUv 1
1
• C`"S 110.1FIS)
9, Control Pollutants. L_
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
( \'P A( r•t�4,k
12. Manage the Project.
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).
1°))
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
I.) 1A
stormwater site plan template.doc—rev.10/12/2003
9
• •
b. Description of special requirements for working in or near environmentally sensi iYFajpaeas. _ �'_
DEC 2 6 =�,.;, ,
/71 1 i
4. Erosion Problem Areas. Description of potential erosion problems on site in the contegtQf the_characteristics ofttc on stte—'
soils(e.g.,erodibility, settleability, permeability,depth, texture, soil structure).
Pl , -
5. Construction Phasing.
a. Construction sequence
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
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 bond and/or other financial securities.
l 1... ¶ +4 5, I uG . — t' 41A-11 t.14,Aa1.. r I I.4
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 Design Calculations on a separate sheet for the folloMng, if applicable.
a. Sediment Ponds/Traps.
b. Diversions.
c. Waterways.
d. Runoff/Stormwater Detention Calculations
storrnwater 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
owners of the affected property.
� V �4, . .... K� lQ '"3a Za p
►+rt� (LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) l ,,,, . diy'4 f (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stordlwater site plan template.doc—rev.10/12/2003 4 12
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