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Home My WebLink AboutBLD2008-00422 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 Al Scalf, Building Official PERMIT #: BLD08-00422 SITE ADDRESS: 91 N LIP LIP LN Issue Date: 12/22/2008 NORDLAND, 98358 Final Date: 1/28/2010 APPLICANT: MAREN H DALE PHONE: 360-379-2619 JEFFREY DALE 872 E MARROWSTONE NORDLAND WA 98358-9573 SUBDIVISION: OLSON & HAMBLETON'S Block: Lot: TX 32 PARCEL NUMBER: 977700049 Section: 9 Township: 29 N Range: 01 E PROJECT DESCRIPTION: NSFR W/ DECKS &A/G 120 GAL PROP TANK THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2006 EDITION. OCCUPANCY GROUP: R-3 TYPE OF CONSTRUCTION: 5N SPRINKLER SYSTEM yes (-ho THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON1/28/2010 I:\F_BLD_Occupa ncy.rpt 10/29/19 I Jefferson County Building Pision Permit NuIr: BLD08-00422 Applicant: DALE BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2006 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 J Setbacks '-",)4) .`(I „ Minimum setback from North Lip Lip Lane right-of-way shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum setback from edge of wetland shall be 75 feet. Erosion Control SEE CONDITION 2 & 3 FOR SILT FENCE AND STABILIZE CONSTRUCTION ENTRANCE. Foundation Footing Footing Drains Foundation Stem Wall I/419/D9 Underground Plumbing Under Floor Framing / ,kr Straps(hold downs) l•'` Ext. Shear Wall Nailing )II 0q. Rough-in Plumbing c-IS Framing � Airseal C(-tc? 177--6 Insulation:Walls `1-11)D`f Insulation: Floors Insulation: Ceiling I1\Oci Int. Shear LNaflir+g Wallboard Nailing Gb �� Gas Line: Interior I g`O Gas Line: Exterior l''2 10 r& Propane Tank t— -i! Heat/Chimney Clearance .6 _04 '- -Di-matt/Alt urainagt SEE CONDITION I FOR SPLASHBLOCK CRITERIA. Address Posted t'A FINAL INSPECTION 1 9- to 11 FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR ItUILDING PERMIT APPLICAIN MLA08-00422 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD08-00422 Received Date: 9/22/2008 SITE ADDRESS: ()\\ N LIP LIP LN NORDLAND, 98358 OWNER: MAREN H DALE PHONE: 360-379-2619 JEFFREY DALE 872 E MARROWSTONE NORDLAND WA 98358 OLSON & HAMBLETON'S 15 SUBDIVISION: Block: Lot: TX 32 PARCEL NUMBER: 977700049 Section: 9 Township: 29 N Range: 01 E CONTRACTOR: WINDHORSE INC PHONE: 360-681-0796 CLIFF LINDEROTH 1017 CHICKEN COOP RD SEQUIM WA 98382 Contractor's License WINDHI*961 BG Expires 1/7/2010 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOP NSFR W/ DECKS & A/G 120 GAL PROP TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 976 VALUATION 325,000.00 ADD'L: 856 HEAT TYPE: EEE CODE EDITION: 2006 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: SHORELINE: CONST TYPE: DECK: 416 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Ioxa1=---�-----� Routing Date: q-az--05 Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $2,253.75 LYK 09/22/08 102767 APPROVED Plan Check $1,464.94 LYK 09/22/08 102767 State Building Code $4.50 LYK 09/22/08 102767 Potable Water Application $59.00 LYK 09/22/08 102767 2z "19 Total: $3,782.19 • • CONDITIONS for Building Permit# :BLD08-00422 1.) DESIGN CRITERIA FOR SPLASHBLOCKS: A VEGETATED FLOWPATH OF AT LEAST 50 FEET SHOULD BE MAINTAINED BETWEEN THE DISCHARGE POINT AND ANY PROPERTY LINE, STRUCTURE, STEEP SLOPE, STREAM, WETLAND, LAKE, OR OTHER IMPERVIOUS SURFACE. SENSITIVE AREA BUFFERS MAY COUNT TOWARD FLOWPATH LENGTHS. A MAXIMUM OF 700 SQUARE FEET OF ROOF AREA MAY DRAIN TO EACH SPLASH BLOCK. A SPLASHBLOCK OR A PAD OF CRUSHED ROCK (2 FEET WIDE BY 3 FEET LONG BY 6 INCHES DEEP) SHOULD BE PLACED AT EACH DOWNSPOUT DISCHARGE POINT. NO EROSION OR FLOODING OF DOWNSTREAM PROPERTIES MAY RESULT. FOR SITES WITH SEPTIC SYSTEMS, THE DISCHARGE POINT MUST BE DOWNSLOPE OF THE PRIMARY AND RESERVE DRAINFILED AREAS. 2.) A SILT FENCE SHALL BE INSTALLED AT THE WETLAND BUFFER PRIOR TO ANY LAND DISTURBING ACTIVITY. THE MINIMUM HEIGHT OF THE TOP OF SILT FENCE SHALL BE 2 FEET AND THE MAXIMUM HEIGHT SHALL BE 2 1/2 FEET ABOVE THE ORIGINAL GROUND SURFACE. THE SILT FENCE SHALL BE BURIED IN A TRENCH TO A MINIMUM DEPTH OF 5 INCHES BELOW THE GROUND SURFACE. THE TRENCH SHALL BE BACKFILLED AND THE SOIL TAMPED IN PLACE OVER THE BURIED PORTION OF THE SILT FENCE, SUCH THAT NO FLOW CAN PASS BENEATH THEE FENCE AND SCOURING CAN NOT OCCUR. ANY DAMAGE TO THE SILT FENCE SHALL BE REPAIRED IMMEDIATELY. SEDIMENT DEPOSITS SHALL EITHER BE REMOVED WHEN THE DEPOSIT REACHES APPROXIMATELY ONE-THIRD THE HEIGHT OF THE SILT FENCE, OR A SECOND SILT FENCE SHALL BE INSTALLED. 3.) CONSTRUCTION ENTRANCES SHALL BE STABILIZED WHEREVER TRAFFIC WILL BE LEAVING A CONSTRUCTION SITE AND TRAVELING ON PAVED ROADS OR OTHER PAVED AREAS WITHIN 1,000 FEET OF THE SITE. THE ENTRANCE SHALL BE CONSTRUCTED ON A FIRM COMPACTED SUBGRADE. QUARRY SPALLS (OR HOG FUEL) SHALL BE ADDED IF THE PAD IS NO LONGER IN ACCORDANCE WITH THE SPECIFICATIONS. (BMP C105, 2005 DOE STORMWATER MANUAL). ANY SEDIMENT THAT IS TRACKED ONTO PAVEMENT SHALL BE REMOVED BY SHOVELING OR STREET SWEEPING. THE SEDIMENT COLLECTED BY SWEEPING SHALL BE REMOVED OR STABILIZED ON STIE. ANY QUARRY SPALLS THAT ARE LOOSENED FROM THE PAD, WHICH END UP ON THE ROADWAY SHALL BE REMOVED IMMEDIATELY. UPON PROJECT COMPLETION AND SITE STABILIZATION, ALL CONSTRUCTION ACCESSES INTENDED AS PERMANENT ACCESS FOR MAINTENANCE SHALL BE PERMANENTLY STABILIZED. 4.) To help prevent seawater from ding landward into underground aquifers, ew development activity on Marrows one Island, Indian Island and within 1/4 mile o any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 5.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 6.) 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. 7.) A setback of 75-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. 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.) 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. 11.) 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. 12.) 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. 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 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 automobile 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 requirements 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.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 17.) The building height is not to exceed 35 feet. 18.) 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. 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.) Minimum setback from North Lip Lip Lane right-of-way shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum setback from edge of wetland shall be 75 feet. , r- 5 i °+ , JEFFERSON COUNTY CEP 2 2 2008 -)j y �,' DEPARTMENT OF COMMUNITY DEVELOPMENT --� ? I ‘r 621 Sheridan Street • Port Townsend•Washingtonn �T �= :, r T 360/379-4450. 360/379-4451 Fax 9836&= - --= " J INC` http://www.coJefferson.wa.us/commdevelopmenV STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# V8-4"2 PROJECT/APPLICANT NAME:c /Wire, 'P / "/C Ye 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 man W e are constructing a 1900 square foot single-family residence near the center of an existing 2.2 acre - -undeveloped piece of land on Marrowstone Island.The land is approximately 270'x335'and is heavily wooded. - -There is a bit of a clearing near the center of the property where we plan to build the house. We will have a short-- p g pad that will be approximately 75'from the building site and will have a wood mulch path up to the house. — Existing Conditions summary 2. Describe the existing topography. Indicate contours on the site map. The build site is almost flat with an elevation gain of+/-2'. The entire lot is relatively flat with small elevation increase at the SW corner and a decrease at the NE corner. The entire property is covered with trees and vegetation. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. The entire property is undeveloped. It was logged 50+years ago.All terrain is covered with trees and legitimation including Douglas fir,white fir, cedar,Alder, maple, salmon berries, back berries, nettles, sticky weed _ and fernsth. 4. Describe e existing soils. Indicate soil type on the site map. _ Casey silt loam ----_ - Indianola sandy loam Analysis by Alkai consultants(see attached booklet for more details). Semiahmoo muck 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. - The soil on this site drains extremely well. There is no puddling or drainage streams after rain has fallen. The . exception is the wetland found at the NE corner of the property which has some water during the wetter parts of . the year. 6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED J STORM-WATER PLAN -Only normal noise associated with constructing a house will be audible during consti'.iction. Stormwa ilk. DEC 1 0 2008 i Require •/Aikl 6, 1EFFER,s N storrmvater site pan template-rev-10/120lkSS DE PT.OF C l �` L SIGNATU .1II�� . Are. s 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 ap. (7frrlr 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.). • The site is located on the SE area of Marrowstone island and sits at an elevation 90-100'above sea level. There is a small type Il wetland to the NE.The property is covered with trees and vegetation and is located in one of the more wooded areas of Marrowstone island. T To the east a private road (Lip Lip N)runs along the southern half of the property line. North of road, the property borders other property lots and is mainly wetland and vegetation covered areas.Approximately 400' farther to the east and past neighboring properties and over a cliff is the Puget Sound. To the north there are neighboring properties and a type Il wetland to the NE. MPs To the west there is a platted unnamed road that was never made.This area remains undeveloped, covered 'ious with trees and vegetation To the south is a neighboring property 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 s pIan all d' a ti ?.proposed facilities from existing facilities. Storm water will be channeled to a via a gutter system on the roof of the house. Storm water on the gravel drive way will be absorbed by the sandy loam soil found on the site. 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.] /41 11. Describe the performance goals and standards applicable to the project. - ------ --- - We purchased this site for its natural wooded beauty and intend to impact the site as little as possible. In order to — maintain the pre-developed we will manage storm water runoff with a gutter system and dry well. In total we will — be only be removing 4 trees to construct the house, driveway and septic system. 12. Describe the flow control system. We do not plan on affecting any existing flows. The site is dry, absorbs water quickly and is relatively level. • • SEP 22 2008 stoanwater plan ale—rev.ronrzooa l ,J_N1 • I 13. Describe the water qualify system. The site is dry, level and absorbs water quickly.There are no pre-existing flow paths where storm water travels. Water from roof will be diverted to a dry well and any water on gravel driveway will be absorbed by heavily vegetation filled surrounding soil. 14. Describe the conveyance system analysis and design. Downspouts will channel water from roof to meµ. .1,1a_c_111,3 ( s_ 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. No fill material is needed. Site is level and natural. 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. Driveway will have 34"minus basalt placed by a truck,compacted with a 5-ton roller. Foundation will have sand under slab, compacted to code with sled compactor. 17. Describe the proposed surfacing material. _3/4" minus basalt for driveway. Other areas near house will be landscaped with wood mulch or a will remain in their natural state. 18. Describe methods for restoration of the site. . Areas affected by work areas will be replanted with ferns from the area and allowed to regrow naturally.The entry driveway will become the final driveway to a 2 car parking pad.A wood chip path will continue to the house.— Any holes or ruts created by machinery other causes will be filled and allowed to regrow natural vegetation. 19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals here. / 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. Wetland Delineation and Analysis Report by ALKAI consultants(included) 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. -Septic system design and permit(Soils Applications, Inc.Sequim, WA) -Wetland delineation and analysis (ALKAI Consultants, LLC. Silverdale, WA) -- �.� SEN 2 2 2008 --a stemmata site plan tenpiate-rev.10/12003 Y :f 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 applicantiowner attest that the information provided herein is true and correct to the best of my knowl-. I also certify that this application is being made with the full knowledge and consent of all owners f the a•= ••-• 22 61 (LANDOW`VER RAUT •' -! ' PRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: S E P 2 2 2008 '' stomiwater site plan terrplate—rev.10/12003 ;l} 12 44,v �N od. JEFFERSOP'itUNTY • 3 DEPARTMENT ../F COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax p www.co.jefferson.wa.us/commdevelopment -4INO�S Master Permit Application MLA: I5-92 — Project Description(include separate sheets as necessary): Ta arcel Number: (/ Property yTj7 a0�v9' p rty Size: Z• /q p`‘4,s. (acres/square feet) Site Address and/or Directions to Property: wae/471 . - cr'/ p. -r a✓ o f d4,�,/ Property Owner(s)of Record: 47 iiz-=a l ii-,' ./P> -e-y ./3 y Telephone: 7�n - '7'}_-- ' /C Fax: email: Mailing Address: „?'7Z ikfc -rrt 1S/r;t_e A h --142-7(1/ L/4' '7, '- S.J) Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies j iBuilding 0 Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) 21 Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a),C(d),orC]** 0 Manufactured Home 0 Modular 0 Discretionary"D"or Unnamed Use Classification ❑ Commercial* 0 Special Use(Essential Public Facilities)** -- • , ❑ Change of Use ❑ Boundary Line Adjustment 0 Address 0 Road Approach 0 Short Plat** ❑ Home Business 0 Cottage Industry ❑Binding Site Plan** ocr 2 2 2008 ,a Propane 0 Long Plat** ❑ Sign 0 Planned Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration**I 1 ❑ Stormwater Management 0 Shoreline Master Program-Exemption/Permit Revisions'*_' "' ) 0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development** ❑Temporary Use ❑Shoreline Management Variance ❑Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference 0 Tree Vegetation Request `*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 its 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 it consequence of the granting of this permit. I further agree to provide ss and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any r ired late insp ' ns. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the app' he o she wa s pri r notice. Signature: Date: The action or act ns Applican ertake 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 are i ompliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transf I p s 'it dhertg to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: Date: G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.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: GENERA CONTRACTOR OR MANUFACTURE HOME INSTALLER: PHONE: 17I6p f (Cl q(Ct('�yAX: 1iv0HoQsE /vc_.,C10 f f L,lcdea-o (" o)-681 071 f0 (3(06)68 ( o79 MAILING ADDRESS: I D-766 cl6 C/£-iteccyZI ,Ch• i418 zEMAIL: Iv/In ri l arse (0) 6( f_[� e4L�� CONTRACTOR'S LICENSE V WAINS u� ( , NUMBER: /, /IV0/4 I qy_rTG_. NUMBER ARCHITECT/ENGINEER: �✓i pitoI kt -�u E' L.z kQ gr- PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shorel•ne: Type of Sewage Disposal: lit New f1 Wood Existing: N lA ❑ Sewer ❑ Addition 0 Steel Proposed: I YZ Bank �t [1 Community System ❑ Alteration/Remodel ❑ Concrete Total: I V _ Height: Do Individual System ❑ Repair ❑ Masonry SEP Permit# O Demolition ❑ Other: Bedrooms: Water Supply: Existing: .® Setback: ❑ Private well i.i Two Party Type f at: Proposed: 3 Public FF -? I-l2 Total: Name of System- P �Q_..0 2. • i If this is a Commercial Protect 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�Above hound Tank? Size of Propane Tank: j 2_ 0 �' �-� i Heat Stove (Cook Stove ' oo dstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / fC� 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 ;ors.- Amount Revision , Main Floor Heated v7‘. ciLla:lodi. EH BId App Review: 70 2 Floor Heated $C> z�(o Consistency Review: !5— - Other Heated d Base fee: Mezzanine Additional Section: Heated Basement Plan Check fee: 14(0 94 Unheated Basement State Surcharge fee: 4.GJD Other Unheated Pot Water Review fee: , 1 , Garage/Carport SUBTOTAL 4)15. i9 Decks q l 6 I (40V 911/ Approach fee: Other — TOTAL: $,1. l • Receipt Number: 10271(51 1E379g2Zg Cash/Check Number: . -53 C_ ESTIMATED COST(REQUIRED) Date: Q -� .F ' market value of all labor and mater�als foundation to finish �I—{-2 (0S. Z_)DCz ---/ Initials: G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc • 110 142'G Il O-1 o-,• � —*it 0o �rz -4s. • 1°� i— ___ - - - ,Io ,zI -4110 Vt(<3.11) ifl I i O • O O O O [ oil ii;--4 i 0 -- — x l�l • / . . , C,N,,,<> , „- 1 —\ �' / W :,:i. m su - -,(..- ; •cr• • _., r/1 i? i , €3 — 1 , „ „.,1,..44,.:„ . ,, IIt -, - "� :rn r' . ,.� ��. � 11 —� � �.+� 'yam ,� 0 � . 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