HomeMy WebLinkAboutBLD2009-00180 ',WILDING PERMIT APPLICAIbN MLA09-0 Review Type:pe: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD09-00180 Received Date: 6/18/2009
SITE ADDRESS: 260 SHORE DR
PORT LUDLOW, 98365
OWNER: VERNON W GOOD PHONE: 360-390-8650
CONNIE R GOOD
260 SHORE DR
PORT LUDLOW WA 98365 PARADISE BAY ESTATES
SUBDIVISION: Block: 4 Lot: 18
PARCEL NUMBER: 983400415 Section: 23 Township: 28 N Range: 01 E
CONTRACTOR: MIKE'S SETUP INC PHONE: (360)373-3129
4201 KELLY RD
BREMERTON WA 98312
Contractor's License MIKE SS1011KC Expires 8/2/2010
REPRESENTATIVE: JO CRITTENDEN PHONE: 253-381-5104
PO BOX 98226
LAKEWOOD WA 98496
PROJECT DESCRIPTIOI NEW M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 1,928
CODE EDITION: 2006 ADD'L: HEAT TYPE: EEE
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Totat--2 --
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 06/18/09 108625 APPROVED
Potable Water Application $62.00 LYK 06/18/09 108625
Total: $275.00 15 2009
Jefferson County Planning
&Building Department
•
SPECIAL CONDITIONS CASE •LD09-00180
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
SPLASHBLOCK.
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.) 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.
3.) The application was reviewed by the Jefferson County Department of Community
Development staff on July 13, 2009 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:
coastal SIZP.
4.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
5.) The parcel is located within stal SIPZ (seawater intrusion protection fa) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
6.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
7.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
8.) The applicant is proposing to create or add 3000 square feet of impervious surface and
2504 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.
9.) 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).
10.) The revised site plan dated July 14, 2009 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 July 15, 2009 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
11.) This approval is for a manufactured home with an attached unheated, unplumbed garage
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.
12.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
13.) A Declaration of Restrictive Covenant has been recorded on August 8, 2001 under AFN
446497 for the purpose of consolidating the lots to meet minimum land area requirements
for on-site septic ad to allow zero lot line setbacks. The Covenant is strictly for building
and septic purposes only.
14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
15.) 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.
16.) This parcel is within Paradise Bay no shooting area per JCC 8.50.
17.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
18.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
19.) The building height is not to exceed 35 feet.
20.) Minimum setback from East Cedar Street and Shore Drive rights-of-ways shall be 20 feet.
Minimum north and west setbacks shall be 5 feet.
21.) 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.
22.) Lighting fixtures shall be desled and hooded to prevent the light source being
directly visible from outside the boundaries of the property. The intensity or rightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
23.) An address of 260 Shore Drive, Port Ludlow has been assigned to the parcel. Shore
Drive is a county local access (C506709).
24.) The parce is served by the Jefferson County Water District#1.
25.) A septic permit(SEP70-0065)was finaled on April 3, 1970 and an expansion done on
January 29, 2002 under SEP01-0091.
26.) The lots were created through the Paradise Bay Estates Subdivision on September 20,
1954 under AFN 142981.
27.) NOTICE: This permit does not excuse the proponent from complying with other local,
state, and federal ordinances, regulations, or statutes applicable to the proposed
development, but consistent with RCW 90.58.
Development pursuant to this permit shall be undertaken subject to the applicable policies
and performance standards of the Jefferson County Shoreline Management Master
Program and the Jefferson County Unified Development Code.
If during excavation or development of the site an area of potential archaeological
significance is uncovered, all activity in the immediate area shall be halted, and the
Administrator shall be notified at once.
The Federal Endangered Species Act rules to protect threatened Chinook and
Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been
listed as threatened since early 2000. Under the ESA, any person may bring lawsuit
against any individual or agency that"takes" listed species (defined as causing harm,
harassing, or damaging habitat for the listed species). In addition, the National Marine
Fisheries Service can levy penalties. All areas in Jefferson County are included as
"critical habitat" for a listed species. Development of property along any marine shoreline,
freshwater shoreline, or floodplains could harm habitat if protective measures are not
taken. To minimize the potential to damage habitat, all property owners developing
adjacent to marine shoreline, freshwater shoreline, or floodplains are advised to do the
following:
-All development activities should avoid unstable slopes, wetlands, and forested areas
near surface waters
- Remove minimal vegetation for site development, especially large trees
-Allow trees that have fallen into surface waters to remain there
- Infiltrate stormwater from buildings and driveways onsite through drywells rather than
discharging directly into surface waters or roadside ditches
Any individual, group, or agency can bring suit for a listed species"taking", even if you are
in compliance with Jefferson County development codes. The risk of a lawsuit against
you can be reduced by consulting with a professional fisheries habitat biologist, and
following the recommendations for site development provided by the biologist. For more
information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and
Wildlife Service.
Dec21 09 09:21 a • p.1
MANUFACTURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD09-00180 Received Date: 6/18/2009
SITE ADDRESS: 260 SHORE DR Issue Date: 7/15/2009
PORT LUDLOW, 98365
APPLICANT: VERNON W GOOD .P 3..60 —ECG,:ik`
CONNIE R GOOD
260 SHORE DR
PORT LUDLOW WA 98365
SUBDIVISION: PARADISE BAY ESTATES Block. 4 Lot: 18
PARCEL#: 983400415 Section: 23 Township: 28 N Range: 01 E
CONTRACTOR/ MiKE'S SETUP INC PHONE: (360)373-3129
DEALER 4201 KELLY RD
BREMERTON WA 98312
Contractor's License MIKE SS1011KC Expires 8/2/2010
PROJECT DESCRIPTION: NEW M/H WITH ATTACHED GARAGE IBLD09-00181)
MAKE: YEAR: SIZE:
Directions SEE DIRECTIONS&MAP IN FILE
To Site:
THIS PERMIT IS VAUD FOR ONE YEAR. •
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED):
Stormwater FINAL Approval:
Blocking/Plumbing -G � *
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval(If not on sewer):
Road Approach Final Approval:
Final/SkirtingNents/Porches/Steps: ��1� - �[N� l.r��" -�. l•
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO O FIN ._INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY REND
BUILDING INSPECTION HOT-LINE 379-4455. � IE,yr �P P+EI~ er
Office Hours 9:00 a.m. -4:30 p.m. mow 4"�L Y
'; :1A ,, cl > w�#a t rri?4 ;c
y Nyy, .Va ,�
HOT-LINE AVAILABLE 24 HOURS A DAY , rc ,Vit
SPECIAL CONDITIONS APPLY-SEE REVERSE
JACK WESTLIIMA,'i ID Jefferson Count•urthousc
ASSESSOR PO Box 1220, Port Townsend, WA 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: �&� tO.
ADDRESS: 7 / ( 7-'�(.( 77.0��/-l' Z( �.3 6.S
PHONE NO. 6 5
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1)MOBILE ROME DATA:
� l (B) MODE �! (C)
(A) MAK(D) LENGTH _ , t./ 4E) WIDTH_ lJ (F) SERI L # L 13, I)
(G) YOUR PURCHASE PRICE (Do not include sales tax) J46/ ,OPURCHASE DATE , L O�i
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE_ �f5
L ADDRESS AC rX p(a WA
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes No
J U N 1 8 2009
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year.
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No
(B)IF LOCATED IN MOBILE HOME PARK:
NAME dic ADDRESS OF PARK Lot/Space #
(CO IF NOT LOCATED IN MOBILE HOME PK:
NAME OF LAND OWNER: V2lnerl dini *03
LOCATION ADDRESS Z { U(�I 1i i Lcti tou) (iT4 q b35
REAL PROPERTY PARCEL #/DESCRIPTION C1834004 l
h
S tare of applicant
THANK YOU FOR YOUR HELP!
Lauralee Kiesel, Property Technician
• 0
w am
11,1_5 . 7 ,
wa 1
in I1.0
..■..1
I qfi q 6
I
♦ N.01•1111 '~ F-{S —___j IW.661 i
C.'-'..7-'.7!-. IN6.-.41 4, tit:
r = ,i, :K
.., 5 Fi h
Sg g
i ii ij;
\, Hi 1 1-3 i,..,..'--)
tp.1. _ _.
r- TWS,ar
fi
IIIM I au !L � .- ,-
I !_ I f
\.F9 N III 1I -,, I 11
a . 4q = a
zs — IN '
L---______ ,_
I : „- )*._._.__\omtrrr__R__A__jimmi —
i-i
r . ,,
7 411 1
e•s s -.
$sa M1. / u
s a I
re)
Z..., ,,,,_, c_ D
-n
IIII PP
_ n
� a c I
c
r 1
n
rt)-P,3-`" rva/ I I,-*/6-0 z//6-" 9 IfYlkikal _:2t__)-z,
0L &J R- vieovc,J G'2gal lc PertLID
a6 o , ms Dgi, fQT 1.up&too , ?83 ,S..5—
1.10' / 41' 6 �'_ 1 (9 REVISED SI E L
dated
- z____ ._ , ` ` Has been APPROVED _
r p(�\S by JEFFERS• i - •
20�g U�c DEPT.OF CO D o V. OP
JUL 1 4 eq �o ,` ' SIGNATURB: ���I�►��•••
f T /7� di
k-; 1
ct
. to 1ac5
2 -Tb
e ,
I,
c2' -
��
♦ ,�
4
r---PrCft \
-,14j kid % ' `�
Oi k ,\ 24'
13,�. _ ,
tot !9
ci '
14 GAS �
, (.1
� � 6
1 4\ .1?"8(4170414 :. 1As
/ 0 ,`•6109
4)61-1
♦'D 1 32/ (-:. 0,
__ _._, v / 19,95' -
u N / 8 2009
III •
1., ,,,6ON'
rod JEFFERSON COUNTY
' '� DEPARTMENT OF COMMUNITY DEVELOPMENT
iw ` '� 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450- 360/379-4451 Fax
,q o www.co.jefferson.wa.us/commdevelopment
HINa
Master Permit Application MLA: Oq -ace c�
Project Description(include separate sheets as.necessary): I
/ Q
Tax Parcel Number: I c.).0 1 Property Size: f Ri / fe(acres/ quare )
Site Address and/orDirections to Property:y: F AD/9$0 l l $1- -ram -� £./- . i,'g Property Owner(s)of Record: V /C.-do/MO IJ La t C.- f' , GvioT
Telephone: qtan
& ._a Fax: email:
Mailing Address:�fPO ..UpPE Rr pO/2-r' . AID ,(i)cq, tij r 92- ‘-
Applicant/Agen (if different from owner): ''O r 2,j re.AJ Lr elv
Telephone: v ~ - Fax: —, email:
Mailing Address: pl o i 9S OA(o i {)D(I _4j '/9
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
❑Building 0 Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Single Family . _ garage Attached/Detached ❑Conditional Use[C(a),C(d),or C]*''
Manufactured Home ❑ Modular 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facil(jiU0**1 8 2009
❑ Change of Use ❑Boundary Line Adjustment
❑ Address 0 Road Approach 0 Short Plat**
❑ Home Business ❑ Cottage Industry ❑Binding Site Plan**
❑Propane 0 Long Plat**
❑Sign - 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑ Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑ 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 ❑Tree Vegetation Request
**Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DE NATION OF AGENT
I hereby designate 0 eel F' to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE /�m. -1,e_..7 fL - 7 Date: &! I7 lcf
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 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 taffs a s and ri ht of entry will be assumed unless the applicant informs the County in writing at the
time of the alp lication that he or she a for noti . /7 (
Signature: ( - 1-e 4l'(- c2J Date: C�` 1-7 0
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 0- Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility or adh it g to and co..Iyin�o}h the ESA. The Applicant has read this dis aimer nd signs and dates it below.
Signature: U /)%2-9_« /T -t Z Date: /-2/0/
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit An„ti,,t;,,,,S_/o_nsz,i,,,-
• •
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 ass ; he re-,oesi�/•TT)D.off'the -neralContractorfortheproposedproject.
Signature: 0 Aa_____ :.,A Date: C� �.-O
GENERAL CONTRAC 'R OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
/Y) 1 =C."� 2 (moo —373— j ( )
MAILING ADDRESS: L/a(/ i 5 F- gR/c V1 3JEMAIL:
CONTRACTOR'S LICENSE 1 '-•�'j •,/ WAINS
NUMBER: / 1 t �`a' s'3 IO// e. 'NUMBER 6 a 2 ` .
ARCHITECT/ENGINEER: ! e2 A S �/ �'-'U�, PHONE ( ) FAX:( ) --
MAILING ADDRESS: , ! EMAIL
~
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
• ew YrlVood Existing: P---- ❑ Sewer
❑ Addition 0 Steel - Proposed: Bank ❑ Community System /,,+i
❑ Alteration/Remodel 0 Concrete Total: `- Height: 0 Individual System-- -4
0 Repair ❑, Masonry SEP Permit# 0i/--9/
O Demolition 0 Other: . Bedrooms: Water Supply:
fn6 Existing: 3 Setback: 0 Private well 0 Two Party
Type of Heat: Proposed: '43'15-ublic pan l4t)LcL
Ek r�C_ Total: -z Name of System: y ,.,
If this is a Commercial Project you must answer the following: /
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food`Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
i Underground Tank i Above ground Tank Size of Propane Tank:
1 Heat Stove i Cook Stove i Woodstove I Fireplace Insert i Hot Water Tank i Pellet Stove i Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying 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.
- � 1 y� i ° ir* �v Nt� a ; r
Square Footage Current Proposed ,� r�+�U c ` £r`, 1 ° ,'r ;T^w _. s,Revision
Main Floor Heated i r± Fr -` EH Bid App Review: 2 ,
2m Floor Heated "t we ' Consistency Review: J
Other Heated Base fee:
1
Mezzanine Additional Section:
-Heated Basement Plan Check fee:
Unheated Basement ',I" ` ; State Surcharge fee:
Other Unheated " ' ' Pot Water Review fee: (
Garage/Carport x_ SUBTOTAL 5-_)
Decks 911/Rd Approach fee:
Other TOTAL: $ (�
`': Receipt Number. I 11 ----'
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: ���� -0n
•Fair market value of all labor and materials foundation to finish
Initials: e------- ��
G:\Pem'tCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc