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HomeMy WebLinkAboutBLD2006-00722 06- •UILDING PERMIT APPLICA1ON MRL Review Ty 684 Ype: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00722 Received Date: 12/27/2006 SITE ADDRESS: WILDWOOD RD QUILCENE, 98376 OWNER: CHARLES D BROWN PHONE: 360-765-0200 SALLY BROWN PO BOX 217 QUILCENE WA 98376 SUBDIVISION: Block: Lot: T 45 PARCEL NUMBER: 702113012 Section: 11 Township: 27 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr NEW STEEL SHOP POLE BLDG - UNHTD, NO PLMB TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 33,984.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: 2,400 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 0 Prop: 0 Total: 0 Total: 0 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $482.15 LYK 12/27/06 Plan Check $313.40 LYK 12/27/06 State Building Code $4.50 LYK 12/27/06 JAN ` 2007 Total: $800.05 _ -.. • • BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00722 Received Date 12/27/2006 SITE ADDRESS: WILDWOOD RD Issue Date 01/12/2007 QUILCENE, 98376 APPLICANT: CHARLES D BROWN PHONE: 360-765-0200 SALLY BROWN PO BOX 217 QUILCENE WA 98376 SUBDIVISION: Block: Lot: T 45 PARCEL NUMBER: 702113012 Section: 11 Township: 27 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: PROJECT DESCRIPTION: NEW STEEL SHOP POLE BLDG - UNHTD, NO PLMB CALL IN FOR THE REQUIRED IN PECTIONS THAT APPLY TO YOUR PROJECT. SETBACKS: o/K 4�tz- 07 UFFER: �lJo Footing: P asT tioc.E5 OK 4/I07// Foundation: Stormwater FINAL Approval: Underground Plumbing: Underground Insulation: Shear Wall : Sheathing: Framing: 2K /p 2/43/ i7 A Plumbing: Propane Tank/ Lines: Insulation: Sheetrock: Septic Sytem Final Approval MUST be obtained before final of structure can be attempted. Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: Qk /D��ZA7' HEALTH DEPARTMENT AND PUBLIC WORKS A R VAL 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 BLD06-00722 1.) An address shall be assigned to the parcel prior to final building approval. 2.) 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. 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 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.) The project is located in close proximity to an identified wetland and is subject to the delineation provisions of Section 3.6.9 of the Jefferson County Unified Development Code. Based upon the proposed location of the project in relation to the identified wetland, the applicant has agreed to maintain a buffer(setback) that exceeds the standard buffer requirements by fifty (50) percent. The applicant acknowledges the additional setback and agrees to maintain the extra 50 percent buffer, therefore, waiving the wetland delineation requirements of the Unified Development Code. 8.) 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 contain the following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation." 9.) A permanent physical separation along the upland boundary of the wetland 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. 10.) 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 steel shop pole building. 11.) An additional setback of five (5) feet is required from the edge of the buffer area to the proposed steel shop pole building. 12.) A permanent physical separation along the boundary of the 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. 13.) 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." 14.) 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. 15.) A Stormwater Site Plan for Medium Project 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. • 16.) Outdoor residential storage shall be maintained in an orderly manner and shag create no fire, safety, health or sanitary hazard. 17.) 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. 18.) Minimum setback from the edge of the Ingress, Egress & Utility Easemnt as delineated on survey recorded under AFN 457128 shall be 20 feet.Minimum side and rea setbacks shall be 5 ft. Minimum setback from the northern property line adjacnet to the Commercial Forest Land Designation shall be 250 ft. Environnmnetally Sensitive Areas further impact setback. 19.) Lighting fixtures shall be designed and hooded to prevent the light source from being directly visible from outside the boundaries of the property. The intensity or brightness of all lighting, during construction and after project completion shall not adversely affect the use of surrounding properties or adjoining rights-of-way. 20.) 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. 21.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 22.) The building height is not to exceed 35 feet. I:\F_BLD_Permit_Buildng.rpt 10/29/19 4, / • • 9\� s���V4Y �� JEFFERSON COUNTY L,is 2 `i : ,� DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 el,,1 i, l�� fi0 360/379-4450 • 360/379-4451 Fax "'ENO http://www.co.jefferson.wa.us/comrndevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# �L PROJECT/APPLICANT NAME: (2)4 p C LC-5 7AZO ui 1 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. 544o1' "ack1 L Jai NC, W is 1-N -BA 5-i- i o ( A FP 2°N S - t 'R°nb Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. (it7 Y sL/c./rL y .ST ct P> A/CC 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. MNPZ. &: j //L1) ; - --i ' A)c=e--= i• st- <- '>1V S . 4. Describe the existing soils. Indicate soil type on the site map. 54A►D y t , L L pi?N/AI 1) . 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. No . TNA,.D/>v G /-2Tic AP ' • -, • , , • II 6. Describe any excess levels of noise generated by the proposed use or activity: * R PLAN II NO E'XC�S S \10 l5 r 111 ' 1 O ,1 fr =III JEFFERSON COUNTY DEPT of :i NMUNITy DEV 0 E, SIGNATURE:la. ' stormwater site plan template—rev.10/1/2003 5 • • N 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. kIE7-z A KI i i M C Nr&� o 0 " P PP-&Ti 5/6Ntc./cwtAir SL©FG: 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.). 5 L 0 PL /S' /so ( Cc,)C-ST 0 f '80 IL D/N 6 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. LlTE7z 5 r- LuN .5 ((7-, c-,N La/ C_hiNG 57'1-)ovi wt r F'l& 4LV- biS1 5ram= / %\( Af/?7`1,ieIV /i 6'E719Ti arL 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.] , N///47; 11. Describe the performance goals and stpndards applicable to the project. M1//V/ m // ,a/i7 r- 12. Describe the flow control system. 5 e,, M to p T R rz_o w Ala 7- nX'f- c- 7- _,Z) �rt - x 1iro.11ci Ls ri' T?Irr i.i,l, .lit: i(1 Ci Lairettlftrelr template—rev.10/12003 6 DEC 2, 7 LUDO L.uuO 13. Describe the water quality system. y' 14. Describe the conveyance system analysis and design. 1rc e + bow ra t5(_4 7-- i)Ric1 i 1.1 7o 7- 0 EDE' aka 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. NCWETh A( C..,/s/// ) /Sc"/< �Nt-ro 5 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 3/95"677 k�' G/C. CO/1 i19c 1 T W 17. Describe the proposed surfacing material. CiC ON 17 fiic#W Iv)/ Nas 18. Describe methods for restoration of the site. REPLJ' N-FL l i-H rig 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. A/X 20. List here and include any special repo s 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. AI 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. Mark Clearing Limits. 1o,E kk, r+u F-L � S 2. Establish Construction Access. 5T/ NG 1ST-/1bNT 1P© =77� 3. Control Flow Rates. ©/ 5- u M H/ N GE7) 4. Install Sediment Controls. P e L Rib S 5. Stabilize Soils. 6. Protect Slopes. 7. Protect Drain Inlets. N/i? stormwater site plan template—rev.10/1/2003 8 C 12 Required Elements-Construction SWPPP(continued) 4NJ 8. Stabilize Channels and Outlet . fi 9. Control Pollutants. 10. Control De-Wat ring(the act of pumping groundwater or stormwater away from an active construction site). N/A2 11. Maintain Best Management Practices(BMPs). b(19 e-le/8611 (.0 t I/1 .1,1 R DINS irb- 12. Manage the Project. S 2L L\LE 11L I7 "iC C,c1/z Dus&--wS 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). Air b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). f 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to tte_pite. stormwater site plan template—rev.10/1/2003 9 • • 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). NoNU " 5. Construction Phasing. a. Construction sequence F'o Cc ti D f 7 M2:Je1 TK 1 b/<EC T 5T 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. CoMpLt 7-7ON ks AFT , P4 Mir ,s541tb II. Wet Season Construction Activities. a. Prnnosed wet season construction activities. k7o>v I ro Gent Pt r ON s bet R i/V 5 (`)/( 57—RL(c T1 Oil( 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. 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 • • 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. 42A,e412 (LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DA1IE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: stormwater site plan template—rev.10/1/2003 12 4SON C' III �� off, • JEFFERSON COUNTY w�' \ DEPARTMENT OF COMMUNITY DEVELOPMENT 04 '4 621 Sheridan Street• Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax 4. p� www.co.jefferson.wa.us/commdevelopment IIINO Master Permit Application MLA: (-1-'r-`(°,�`1 Project Description(include separate sheets as necessary): amNL`--A T--FD 57Ic% P T& it. b1I\IC No ti11vialNC Tax Parcel Property Number: 7C 2- 1/3 0/2_ Size:,2 Ca/C,4.63 (acres/square feet) Site Address and/or Directions to Property: wj L j WOO])Property Owner(s)of Record: ehl kI L._L`_.-_S ►h i2OLL% N Telephone: •3 6-o "C 5 -- C,,C() Fax: email: Mailing Address: 9c' 1r AI G7-mi S T, OtA 1 LCc-i\I IT / V 6 3 74- Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) taeuilding ❑Variance(Minor, Major or Reasonable Economic Use) [j Demolition Permit ❑Conditional Use[C(a),C(d),or C]** Cj Single Family °Discretionary"D"or Unnamed Use Classification al Garage Attached etached� °Special Use(Essential Public Facilities)** ❑Manufactured Home C]Boundary Line Adjustment 1=1 Modular °Short Plat** ❑Commercial* °Binding Site Plan** Q Change of Use 0Long Plat** El Address i Road Approach [°Planned Rural Residential Development(PRRD)/Amendments** Et Propane ❑Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑Shoreline Management Substantial Development** OSite 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 OForest 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 designatealA Li&'- pt)ki to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE CA4.1412 ?"(,c� Date: /2-" ‘,2-7 - oL 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. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the applicatiop that he r she wants prior no Signature: / �- 7 06 Date: 6 The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfe e resnsibility for dhering jad complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. ASignature: N 4-, fI . 'E 2.t r,` Date: I).— ,c27" D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc • • BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be asssuumipg the rr ponsibili of the f-,eeral Contractor for the proposed project. Signature: ( , a.A,Lio �+�J�-4�-(✓`-� Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: k f lk /k ET PHONE ( ) FAX:( ) MAILING ADDRESS: q(.4)( ill Aso N $t fa -r, Wil 43 EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ® New 0 Wood Existing: .• fi'Sewer ❑ Addition ® Steel Proposed: Bank 0 Community System ❑ Alteration/Remodel 0 Concrete Total: Heigh ,,Individual System ❑ Repair ❑ Masonry �1 SEP Permit# ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well 0 Two Party Type of Heat: Proposed: ❑Public NpN L- 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 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: L1 Underground Tank 0 Above ground Tank Size of Propane Tank: °Heat Stove 0 Cook Stove 0 Woodstove ❑Fireplace Insert 0 Hot Water Tank 0 Pellet Stove p Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH Bld App Review: IA.N C._..�` 2nd Floor Heated Consistency Review: 1`---- . Other Heated Base fee: Mezzanine Additional Section: Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: 11 6; Other Unheated Pot Water Review fee: ) O A n Garage/Carport SUBTOTAL f�l ( f T� Decks (1 iiiRd Approach fee: i ;:— lid Other 5 4o !� �i G0 J� S TOTAL: $ 1 t ar3: l.'t.� T f- Receipt Number: 1(..)'D i Cash/Check Number: ESTIMATED COST(REQUIRED) � Date: .Fair market value of all labor and materials foundatio isn lab-7 L ir 30,et—no,, Initials: -, - D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc ---N f., -1-,T —. CX:3--A. .. .:-. ..e.,k.....4,101 it-T _ _ _ ---- --, • k • monso _ r- • . ..,., , . _. . . ......_ _..... _. ...,..____ ... _ „,. 1 . . . . 111 . . (I'' . . 0 cf. _ .....................7 , tyi 7,1 , ; •, c• •.? • , 0 A 1', \--- . , • . 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