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HomeMy WebLinkAboutBLD2007-00210 07 illkILDING PERMIT APPLICA•N MRL Review Ty 235 ype: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00210 Received Date: 5/10/2007 SITE ADDRESS: PORT HADLOCK, 98339 OWNER: MICHAEL J NOVACK PHONE: 360-437-2628 SARA L NOVACK 2840 OAK BAY RD PORT HADLOCK WA 98339 IRON DALE AC TRACTS SUBDIVISION: Block: Lot: TR 15 PARCEL NUMBER: 962700019 Section: 12 Township: 29 N Range: 01 W CONTRACTOR: S B C CONSTRUCTION PHONE: (360)732-7530 PO BOX 1228 PORT HADLOCK WA 98339 Contractor's License SBCCOC1961JT Expires 4/26/2008 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI NSFR W/A/G 250 GAL PROP TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,265 VALUATION 160,818.00 ADD'L: 295 HEAT TYPE: PRO CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: CONST TYPE: 5N OTHER: 133 SHORELINE: GARA CONST TYPE: DECKLE 385 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date:_n -:51 (01 Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $1,335.35 LYK 05/10/07 89940 APPR \/EEPlan Check $867.98 LYK 05/10/07 89940 State Building Code $4.50 LYK 05/10/07 89940 Potable Water Application $58.00 LYK 05/10/07 89940 AUG I 2007 Total: $2,265.83 Jefferson County Planning &Building Department Jefferson County Building Division Permit Nur r: BLD07-00210 Applicant: NOVACK BUILDING PERMIT INSPECTION APPROVALS kpplicable Code: 2003 International Building Codes To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection. Requests received after 7:00 AM will not be scheduled for that day's inspections. ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries. The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection Inspection Item Date Approval Signature Notes Setbacks V Erosion Control gib f Foundation Footing /a/I/al0I l lO UFFEk. Footing Drains Foundation Stem Wall i944/67 # '44 Underground Plumbing kV-A Under Floor Framing 3/3J08 Ok Straps(hold downs) ,!/i9/Di. f' EPJ & 6rRAPS 9k 4/3/AB 0 Ext. Shear Wall Nailing 1(�3 00 # .K Rough-in Plumbing ,j Z9iGg Framing g124/erg U" !' ( /'iirleil�/Uk Blocking #7-9 /� U, t" Airseal �//z1/ fr' Uh Insulation:Walls 5/2/08 n; Insulation: Floors CJ/23/0A ' dK Insulation: Ceiling 0 3/na3 fI r ' Int. Shear Wall Nailing N/ Wallboard Nailing 5/8/Gb ;i o Gas Line: Interior Q/r J 2',$)g 77 Gas Line: Exterior N/A Propane Tank /Nth fil ,_ 7r.,1 -6e...ft ks. Heat/Chimney Clearance ....I:2Fte k-T Fi a4 IN friektrr — j c-Clt Drywell/Alt Drainage 0 3/og Address Posted g73hs FINAL INSPECTION /�4/0 ,..#, d/g Xr- (VP FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR • • CONDITIONS for Building Permit# :BLD07-00210 1.) PRIOR TO OCCUPANCY AND BUILDING FINAL--APPROVAL OF SEPTIC SEP07-13 IS REQUIRED. 2.) The application was reviewed by the Jefferson County Department of Community Development staff on June 8, 2007 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: wetlands on-site. 3.) 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. 4.) A setback of 225-feet, measured perpendicularly from the wetland edge, shall be permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the wetland or its buffer is allowed. 5.) Wetland 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." 6.) 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. 7.) The applicant is proposing to create or add 5280 square feet of impervious surface and 10,358 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 8.) 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. 9.) 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. 10.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i). 11.) The site plan as submitted with the building permit application on May 10, 2007 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications,.changes, and/or additions to the stamped, approved site plan dated June 8, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 12.) This approval is for a single family residence with a 250 gallon above-ground propane tank only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 14.) Not more than 2 unlicensed vehl shall be stored on any lot unless totally ned 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. 15.) 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. 16.) 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. 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.) Minimum setbacks from platted rights-of-ways shall be 20 feet. Minimum south property line setback shall be 5 feet. Minimum setback from South White Fir Way(front yard) shall be 20 feet. 20.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 21.) The parcel has been designated as RR 1:20 under the Jefferson County Comprehensive Land Use Map effective August 28,1998. 22.) An address of 12 South White Fir Way, Port Hadlock has been assigned to the parcel. South White Fir Way is private. 23.) The parcel was created through the Irondale Acre Tracts Subdivision on December 12, 1910 under AFN 31830. The plat was amended on April 8, 1991 under AFN 339373. 24.) A stand-a-lone stormwater permit (BLD07-0127)was approved on April 5, 2007. A septic permit(SEP07-0013)was approved on February 16, 2007. A road approach (RAP07-0033) was required for 911 and to name the road. 25.) The parcel is served by PUD #1 water. • 0 ,r, ..,0 , Tf� f 4)t; i ) C ON cowJEFFERSON COUNTY'_ > DEPARTMENT OF COMMUNITY DEVELOPMENT arnz �. TgC621 SheridanStreet• Port Townsend•Washington 98368 L i iik f ijNG�O 360/379-4450 . 360/379-4451 Fax �•'= Yt tr;�irl http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# (- � )r—D PROJECT/APPLICANT NAME: t vk t L.c c.. µti,({{ .fj f 1 t4 0 J 0-£ L. 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. \. 0k \:. (1 \e A rCA Existing Conditions Summary �; - T 2 2. Describe the existing topography. Indicate contours on the site map. T O n(IN t fl U 11 f T1/ !Tr 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. ( \P.A+t0.A ON AAA 4. Describe the existing soils. Indicate soil type on the site map. 0„1,\ck.: ` 1'0C>v\A„Lit O't ` ;:kl"' 6\fA0%1(.U{ 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. V C\A W t,t7'k L\,'1 P! R C,ef"C t,l A.!, kC'; L51\k') a.t �Nc A: .c w l�t' t€v, . eAk.(a k,.Q ,-:..(_A( Pt&AA. e\1, 6. Describe any excess levels of noise generated by the proposed use or activity: Ao Ywa C.��vt`� Ltc t,r;A LLn, (y\=krJW ; .f PP 1 OVED r. c �� Z1 AT LA )o \ ir,t^u _s ER PLAN JUN - 8 2007 stottnwater site plan template.doc—rev.10/12/2003 r 5 StorrnW r JEFFERSO UN Y Require DEPT.OF��T EVA`OP ENT SIGNATUR : J v • 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. 8. Describe the general vicinity of the site,including adjacent land uses and structures, utilities, roads, and sensitive/critical areas etc.).( r`m c glands, lakes,ce `steep slopes, + c ; i 't G ri �� '0 V Q�.t r. E?. �r Ol ticck Miles( `T1`,(n L <r p k.\k t z.( ck.s; t.r_ rY' - z acl<s r A. 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 witt ip r LA 1l n the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. e t- i \ "}...,:,,4 l A�t 1, C �!.: Ck.( f„JQ:�': i..:.. CS'ikAA. Y VCR--1t. A-w.--- U l _i g �ti Y 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. VA o (kir c�v�r�o < , lei W �� (x-c- ak 12. Descri a the flow control syslem. RECEIVED stormwater site plan template.doc—rev.10/12/2003 � N fCO • • 13. Describe the water quality system. 14. Describe the conveyance system analysis and design. 15. Describe the source of fill material, physical characteristics of flu 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. •r 18. Describe methods for restoration of the site. �J cnr W t.tra. cut LA Qom, t!-'l l 0,k . —� 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 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. i'r stonmwater site plan tempiate.tbc—rev.10/12/2003 , .') `ivC;v ��vautl i rvu • • 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. L lit . ,I:. .{•• t,i � C�: � i G+C"tx�:� t tQx"ti..t, 1_ \ 2-- 2. Establish Constru tion Access. • 3. Control Flow Rates. 4. Install Sediment Controls. 5. Stabilize Soils. 6. Protect Slopes. 7. Protect Drain Inlets. stormwater site plan template.doc—rev.10/12/2003 8 tY�uNi`,1iovJrY��4rVbL s _ • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 9. Control Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). 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).. Arkr t.t3 L b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). y { Iro..uin e. Pk-Or t-�, Gam,tf�.f� i .1. (:a Q "G1{�` -4-0 "\�f - k'ctrk.a LA,-4. ( � Q t-k GAG O ti) 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or Adjacent to the site. }� SC a-4 6e:C1(- tt `AA .Ca, i�jnc. e? , Tc15k S ft J.T RECEIVED stormwater site plan template.doc—rev.10/122003 .� '�fFHSl P R 1l1.11 N Y (JCO • • b. Descrip ion 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). ii 5. Construction Phasing. a. Construction s quence r -CALe.Uf 1 W -Ot t N/�rti<(k.` '1 ll'!"z -eta ,ttl1P t.,.,.. uke," VIA-,L.c� b. Construction phasing(if proposed) qV\ 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. provide a proposed construction sched le. I I �D-1- e l tr,\ i ', tr ro-� -�-ptru�. . . 1 CNr, -1 ( 0-1 ` -a,u.A tin I o -I "- -1 v\ te,\^ttv"Ec II. Wet Seasonconstruction Activities. a. Pro osed wet season construction activities. 'AkL-V\ c1Vlsr4, (IN \V\Gt b. Proposed wet season construction activities for environmentally sensitive areas. i— \�` 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. 6tt -t ° 1tia ,c 14cvo. L. b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts.� 14 Ck 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. V` b. Diversions. c. Waterways. d. Runoff/Stormwater Detention Calculations ][(1Iit./ 1 1K t stemiwater stte plan template.doc—rev.10/12J2003 10 i.iiiLIi ifi. .A;UitiI Eu • • 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 y nowled e. I also certify that this application is being made with the full knowledge and consent of all owners fUe2 r er VC)7 (CA OWNER OR AUTHORIZED REPR ATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: stormwater site plan template.6x—rev.10/12/2003 12 ww�,gON O \\ JEFFERS•COUNTY ~( I `, �! ik' I! III DEPARTMENT OF COMMUNITY DEVELOPMENT ti ` ''4 621 Sheridan Street• Port Townsend • Washington 98368 �.- , 360/379-4450 • 360/379-4451 Fax p� www.co.jefferson.wa.us/commdevelopment sHINCa Master Permit Application ,-� ss MLA: CD ( - ;.�' . � Project Description(includ eparate sheets as necessary �� `"�� � t i 'J . t 4\C'I LE, it-A nA,t L_`I R E s l E tit c E • . '49 ,`�,)-?r4,' Tax Parcel Property i f ( Number: �ifj Z , 0�() t9 Size: "tl L/'7 q(�Z,ZO(acres/square feet) Site Address and/or Directions to Property: tiVAt>at . A�- -�a� ��a ('1'3 1 -t � onrC>,L 4 �� -- ( .L Pt 1t� : a-4e,) Property Owner(s)of Record: OA-1CLk. ft L. `a S ir1<KA NA O V VA,c lL Telephone:3 () i-t 3'l - Z.(c,L -j Fax: email: Mailing Address: 2-k 4 0 i._)P K ?,A 4 R , Po tz-T H 1AD Lock_ t 3 A g£.3 3 9 Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies igiBuilding 0 Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit 0 Conditional Use[C(a),C(d).or C)** 21 Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)** ❑ Commercial* 0 Boundary Line Adjustment ❑ Change of Use 0 Short Plat** Ca Address 0 Road Approach 0 Binding Site Plan** ❑Home Business 0 Cottagelndustry 0 Long Plat** f&Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑Sign 0 Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑ Shoreline Management Substantial Development** ❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment ❑Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request *May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal,if known: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that be or she' is prior notice. r Signature:t /`,' _ .` Date: t� fAr. �) 7 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-trans/fer8ble responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: ,% Date: _)//e/r) 7 i , - , C:\Documents and Settings\can'\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.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 assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: -fin C ft l__l✓v(\<j-r-t I C <>tn ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ix—New Wood Existing: J Sewer J Addition U Steel Proposed: 2. Bank J Community System J Alteration/Remodel U Concrete Total: ,__ Height: U Individual System J Repair U Masonry SEP Permit#1"T- Col-3 J Demolition U Other: Bedrooms: Water Supply: Existing: Setback: u Private well J Two Party T e of Heat Proposed: - ,t Public `VCOv.t.v\Q, Total: a Name of System:'t.1b" C.Aurrv.fe,,,:\ (L1-.:kCr`5(-t9-C' If this is a Commercial Proiect 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: 0 Underground Tank KAbove ground Tank Size of Propane Tank: 7%)0 0,c.l6\ ❑Heat Stove all Cook Stove 0 Woodstove ❑ Fireplace Insert of Water Tank 0 Pellet Stove 0 Other Is this appliance being installed in a Manufactured/Mobile Home? Yes N; 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 acer { I '. ' .- EH Bld App Review: 21tl Floor Heated 96------- ;y 4 , . Consistency Review: I Other Heated ! Ici 7.', /=1 Base fee: , 3r� OL «MO(y /23 , >_ � Mezzanine Additional Section: Heated Basement Plan Check fee: CMG Unheated Basement State Surcharge fee: I` JL Other Unheated Pot Water Review fee: F�,9j 0L. Garage/Carport SUBTOTAL Decks --)r C (lc Kt T-.) 911/Rd Approach fee: Other TOTAL: $,3I-5,, 1 f Receipt Number: CI C11f. Cash/Check Number: ESTIMATED COST(REQUIRED) lI ��. 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