HomeMy WebLinkAboutBLD2007-00221 ItILDING PERMIT APPLICAT•N MR 07N002240
Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00221 Received Date: 5/11/2007
SITE ADDRESS: '(p I HIGHLAND DR
PORT LUDLOW, 98365
OWNER: SHANNON MC CASLIN PHONE: (360)478-2701
JAMES H FRYE
3444 CIRCLE WAY NW
BREMERTON WA 98312 SOUTH BAY#1
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 995500005 Section: 21 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: STEVEN CROSS PHONE: (206) 786-5526
46 VILLAGE WAY
PMB 124
PROJECT DESCRIPTIOP NEW SFR W/ATTACHED GARAGE
ALSO A/G 120 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2,400
VALUATION 275,000.00 ADD'L: 377 HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: 760 SHORELINE:
CONST TYPE: DECK: 96 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: SEW
WATER SYSTEM: LUDLOW
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
5//1 Ie7 c--.
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,973.75 KAS 05/11/07 89896 APPROVED
Plan Check $1,282.94 KAS 05/11/07 89896
State Building Code $4.50 KAS 05/11/07 89896 JUN 2007
Potable Water Application $58.00 KAS 05/11/07 89896
Total: $3,319.19 Jefferson County Planning
&Building Department
Jefferson County Building DSsion Permit NJ,: BLD07-00221
Applicant: MC CASLIN
BUILDING PERMIT INSPECTION APPROVALS applicable 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
Erosion Control
Foundation Footing 7/5/7 A% �,/FGEB ��)s?A4LED
Ar Footing Drains 0°7 i
Foundation Stem Wall / O
V/3/07 y�o-4410ws iN rLAGC-
Underground Plumbing /JAlt
Under Floor Framing g/17/� �/ b K
Straps(hold downs) 9/z/0 7 vA "
Ext. Shear Wall Nailing
g 7.40/0-) irr 6(
Rough in Plumbing 9/Zg/67 lr
Framing /06/O7 is j14
Blocking 0 /V
Airseal q/Zd OT .„.
Insulation:Walls WO 57 Dt_
Insulation: Floors /Deb/ / a�
Insulation: Ceiling 'Nag �f ,- // ,, /
/ 9 ag i IhuLfi�D GeIL1N45OK t0/6/1l�¢
Int. Shear Wall Nailing ,tv `L_ 1 v I
Wallboard Nailing
10 1b 1 \)•\‘ \
Gas Line: Interior 9/zb/c! c/Q1/
Gas Line: Exterior Jq/A.
Propane Tank Oh 13
i
Heat/Chimney Clearance /0/0/07 ;I FRONive- P
Drywell/Alt Drainage /
d9* Ll r?Utl� Di5 P�,es/u� l,e6ut�!
Address Posted tog c"
FINAL INSPECTION //Q/OB A/ Di(/ -Pet- 0 //q/i,4'
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD07-00221
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on June 13, 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:
Osprey.
2.) The applicant is proposing to create or add 5182 square feet of impervious surface and
7159 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.
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.) 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).
5.) The revised site plan dated June 18, 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 22, 2007 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
6.) This approval is for a single family residence with attached garage and 120 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.
7.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
8.) Not more than 2 unlicensed vehicles shall be stored on any lot unless totally screened
from view of neighboring dwellings and rights-of-way. Such screening shall meet all
applicable performance and development standards specific to the district in which the
storage is kept, and shall be in keeping with the character of the area. Screening shall
meet the requirements of Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor
vehicles is prohibited except in those districts where specified as an autormobile wrecking
yard or junk (or salvage) yard and allowed as a permitted use in Table 3-1 or Chapter
18.18 JCC, and such storage shall meet the requriements of JCC 18.20.100, Automobile
wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor
vehicles be stored in a critical area.
9.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
10.) Per MPR Code Section 3.17, accessory dwelling units (ADUs) shall not be allowed in the
MPR-SF zone.
11.) The building height is not to exceed 35 feet.
12.) Minimum setback from Highland Drive right-of-way shall be 20 feet. Minimum side and
rear yard setbacks shall be 5 feet.
13.) 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.
14.) Lighting fixtures shall be designind hooded to prevent the light source froaing
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.
15.) Maximum lot coverage is not to exceed 45%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
16.) The parcel has been designated as MPR SF4:1 under the Jefferson County
Comprehensive Land Use Map effective August 28, 1998.
17.) The lot was created through the South Bay#1 Subdivision on March 3, 1975 under AFN
227194.
18.) A road approach permit (RAP07-0072) will be issued with the building permit.
19.) The lot is served by Port Ludlow water and sewer.
20.) Per email dated March 15, 2004 from Jeff Davis, WDFW biologist, Osprey are no longer a
priority species.
21.) An address of 161 Highland Drive, Port Ludlow has been assigned to the lot. Highland
Drive is a county local access (C507809).
22.) THE ROAD APPROACH PERMIT (RAP06-0229) MUST E INSPECTED AND FINALLED
BY THE JEFFERSON COUNTY DEPARTMENT OF PUBLIC WORKS PRIOR TO THE
FINAL INSPECTION/CERTIFICATE OF OCCUPANCY OF THIS RESIDENCE.
CONTACT TERRY DUFF AT THE DEPARTMENT OF PUBLIC WORKS AT
360-385-9159 FOR THE FINAL ROAD APPROACH INSPECTION.
R
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, 4�4 n c�� JEFFERSOf UNTY ` `��' ���' ��
rtDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368 MAY
360/379-4450 • 360/379-4451 Fax
,gS, N0�p www.co.jefferson.wa.us/commdevelopment Eff� l�`+ I'uu�� NlVlii,ii
Master Permit Application MLA: I Q'1- qvL)Ol
Project Description (include separate sheets as necessary):
Tax Parcel Property
Number: Cicl --CM e.) c) J Size: T t , n"_j /�
(acres/square feet)
Site Address and/or Directions to Property:
H dcj� 446/10 0,-- 12 pave--9`sue bitty reel/A-c.IZ-r +o H�`��l",o ,��-�-
Property Owner(s)of Record: S1igGc.pth•p c` We._e44 1;,
Telephone: 3 60-cf-)$^ 2'Icy ) Fax: email:
Mailing Address: 3gc(t( e, 4�re. 6J447 .tip ti c-Ank W &4 T gz/Z
Applicant/Agent(if different from owner): 5-tcc/<k erxo 53
Telephone: 2oC ? "s-2‘ Fax: email:
Mailing Address: '6 LA ( 4f'i e. �T Pr,•.ii3 /2 le /?a.A-7" [rw 4 co t-cJu g if 3 C.5—
What kind of Permit?(Check each box that applies —
t4Building 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a), C(d),or C]**
JXSingle Family Garage Aged/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**
PlIp. Address Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry 0 Long Plat**
I_WPropane 0 Planned Rural Residential Development(PRRD)/Amendments**
Di 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 c_Jz e,„as to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE_ ,L�4,� ,A pn J / 1/t GC4� J Date: 41— 2-6—4f,'7
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 eritry will be assumed unless the applicant informs the County:in writing at the
time of the application that he or she wants prior otice.
Signature: ,�,t C 2- G p
Date: 41.—
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-transferable for adhe 'ng to an omplyi g with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: u 1LA ! Date: q— 2 6 -D
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
110
BUILDER STATEMENT IP
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 Co actor f the proposed project.
L l
Signature: 4J1JU A,41&) /.LC Date: /ux !/
o 7
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: 1;`•`t'IL &)J NUMBER
ARCHITECT/ENGINEER: q&d , ', , 5O S': PHONE �.Y6 )3t-� 6. f' : ( )
MAILING ADDRESS: /4,4- 1oc,),1 mot(,--1 ) t-J Gif 1936EMAIL 61/6i..i-f+CGT,Svv(best-. 4 0--
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
p'New Wood Existing: - Sewer
Addition 0 Steel Proposed: „4,_
Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: Z Heigh : ❑ Individual System
❑ Repair 0 Masonry :�J/'¢ SEP Permit#
0 Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well 0 Two Party
Type of Heat: Proposed: 3 , ' 2 Y>Public
- _.fiV C- Total: r�`1/11✓r' Name of System: =4.-t-i J4 i 0
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:
i Underground Tank i A ve gceend--T nk Size of Propane Tank: /2.6 �Y
i Heat Stove ook Sto - stove Fireplace Insert i Hot Water Tank i Pellet Stove i Other j,„2'77R c
Is this appliance being installed in a Manufactured/Mobile Home? Yes / v✓ r `
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 BId App Review: _ —
�yov
avlEa.u.
2nd Floor Heated 3 .7 7 35 wt 5 f onsistency Review: C CAD
Other Heated •l/A Base fee: ICI rla
r r 7,5
Mezzanine v� Additional Section:
Heated Basement ��� Plan Check fee: I ay. q
Unheated Basement ��� State Surcharge fee: LI So
O h Pot Water Review fee: (� )
G i .o A 10) ,'>/'�► _` l/l/
* � SUBTOTAL
760 )1C0- av 5.51f. 19
Decks tilA`I - A 911/Rd Approach f : 1
5D-CD
Other u IIA' 'I TOTAL: $ 5q )
iU I+HSUN)MIfN1 III Il Receipt Number: 69 D c ( +
Cash/Check Number: 00 5
ESTIMATED COST(REQUIRED) a(c,Gi 6,7,.qj Date: � t ' U r�
•Fair market value of all labor and mater/a ' to fihish ` ( /
-2. 13'-Oct,CD Initials:
6
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
,. 1 • •
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JEFFERSON COUNTY
... DEPARTMENT OF COMMUNITY DEVELOPMENT MY 1 I Zikt?
, , 621 Sheridan Street • Port Townsend •Washington 98368
.114947 ° 360/379-4450 . 360/379-4451 Fax I[[[[Q`JIa 1 al1IMI 1 1i
N http://www.co.jefferson.wa.us/commdevelopment/ �JEf f fliS] ) ,U ,
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# 0 7- .4 D PROJECT/APPLICAVT NAME: ,s ue . ,A1/6- e 6 /,`kl
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. /,
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map. 1.1iN 1Y BCD
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
4. Describe the existing soils. Indicate soil type on the site map.
64-V10 i/L)4, Jae 1'0 ((
5. Describe the existing site hydrology(i.e., drainage;behavior of water on the site—above,below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of each.
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6. Describe any excess levels of ndse generated by the proposed use or acti '► •• /
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map.
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.).
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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.
9. 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.
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10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
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11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system. 4
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13. Describe the water quality system.
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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.
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.
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18. Describe metho s for restoration of the site.
`71— e.f) ac
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.
4)74
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
(4-
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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MAY 2007
stormwater site plan terrplate—rev.10/1/2003
• •
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.
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes.
7. Protect Drain Inlets. �(
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• •
12 Required Elements—Constriction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
47(114-
11. Maintain Best Management Practices(BMPs).
12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads).
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). (� f
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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b. Description of special requirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure).
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5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation 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
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable.
a. Sediment Ponds/Traps. I 'IA� ������
b. Diversions. - �'9
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d. Runoff/Stormwater Detention Calculations NY
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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.
c RCS —"' "v C. /07
(LAN WNER OR AUTHORIZED R PRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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