HomeMy WebLinkAboutBLD2010-00076 •
•
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 #: BLD10-00076
SITE ADDRESS: 60 LILLIAN ST Issue Date: 04/19/2010
CHIMACUM, 98325 Final Date: 11/17/2010
APPLICANT: MAUREEN R KUDRONOWICZ PHONE: 360-385-7012
ROBERT A JOHNSON
PO BOX 384
PORT WA
SUBDIVISION: OLSON SDLOCK TO IRO DAL83E 390384
Block: Lot 1+
PARCEL NUMBER: 978300104 Section: 10 Township: 29 N Range: 01 W
PROJECT DESCRIPTION: NEW M/H REPLACEMENT
MODEL:KLDT-69207 - SER# 33321
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2006 EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes o
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON
11/17/2010
I:\F_BLD_Occupancy.rpt 10/29/19
MANUFA•URED/MOBILE HOME INST•LATION PE
RMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD10 00076 Received Date:
SITE ADDRESS: 60 LILLIAN ST 3/22/2010
CHIMACUM, 98325 Issue Date: 4/19/2010
APPLICANT: MAUREEN R KUDRONOWICZ
ROBERT A JOHNSON
PO BOX 384
PSUBDIVISION: OOLSORTN SDTO IRONDALE 983390384CK WA
Block: Lot: 1+
PARCEL#: 978300104 Section: 10 Township: 29 N Range: 01 W
CONTRACTOR/ BUY RITE HOMES PHONE: (360) 681-0777
DEALER 259403 HWY 101
SEQUIM WA 98382
0
Contractor's License BUYRIH`0840B(3EOixp es 381-05/20/2010
PROJECT DESCRIPTION: NEW M/H REPLACEMENT
MAKE: KARSTEN MODEL:KLDT-69207 - SER#33321
YEAR: 2010 SIZE: 70X28
Directions
To Site:
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 re ' " Minimum setback from Lillian Street right-of-way shall be 20 feet.
Minimum side and rear yard setbacks shall be 5 feet.
Erosion Control SEE CONDITION 2
Drywell/Alt Drainage SEE CONDITION I
`_t__o Tim ID --21z)-to .
FINAL INSPECTION //'/7','I)/1
(24- ;
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY- SEE REVERSE
EOLDING PERMIT APPLICATIO MLA 01
Review ew T Typype: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD10-00076 Received Date: 3/22/2010
SITE ADDRESS: 60 LILLIAN ST
CHIMACUM, 98325
OWNER: MAUREEN R KUDRONOWICZ PHONE: 360-385-7012
ROBERT A JOHNSON
PO BOX 384
PORT HADLOCK WA 983390384 OLSON'S TO IRONDALE
SUBDIVISION: Block: Lot: 1+
PARCEL NUMBER: 978300104 Section: 10 Township: 29 N Range: 01 W
CONTRACTOR: BUY RITE HOMES PHONE: (360) 681-0777
259403 HWY 101
SEQUIM WA 98382
Contractor's License BUYRIH*0840B Expires 5/20/2010
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW M/H REPLACEMENT
MODEL:KLDT-69207 - SER# 33321
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,860
VALUATION ADD'L: HEAT TYPE: EEE
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: 32 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 2
Total: 2 Total: 2
Routing Date:
3-2 0
Type Amount Pai By: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 03/22/10 114036 APPROVED
Potable Water Application $98.00 LYK 03/22/10 114036
Total: $311.00 APR i1 201U
Jefferson County Plannint
& Building Department
•
SPECIAL CONDITIONS CASE # BLD10-00076
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.) USE OF THE EXISTING SEPTIC SYSTEM REQUIRES GRAVITY FLOW INTO THE
EXISTING SEPTIC TANK. SHOULD A PUMP BE NEEDED TO GET SEWAGE TO THE
EXISTING SEPTIC TANK THEN A PERMIT FROM THE HEALTH DEPARTMENT WILL
BE REQUIRED.
APPROVAL OF A SOLIDS OR GRINDER PUMP TANK CAN NOT BE APPROVED.
4.) The application was reviewed by the Jefferson County Department of Community
Development staff on April 12, 2010 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:
SARPA & SUSC aquifer recharge area.
5.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson County.
6.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
7.) Critical Aquifer Recharge Ar are defined as Seawater Intrusion Areas, Special
Aquifer Recharge Protection reas and the following land uses located wit in Susceptible
Aquifer Recharge Areas (1) All Industrial Land Uses (2) All Commercial Uses (3) All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit (4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit (5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
8.) 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.
9.) The applicant is proposing to create or add 1188 square feet of impervious surface and
1188 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology 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.
10.) 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.
11.) 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).
12.) The site plan as submitted with the building permit application on March 22, 2010 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 April 15, 2010 shall be resubmitted for
review and approval by,Jefferson County Department of Community Development.
13.) This approval is for a replacement manufactured home 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.
14.) The parcel has been designated as UGA- low density under the Jefferson County
Comprehensive Land Use Map effective August 28, 1998.
15.) A Restrictive Covenant for Irondale/Hadlock Sanitary Sewer System No Protest
Agreement was recorded on April 14, 2010 under AFN 551154 with the Jefferson County
Auditor.
16.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
17.) Not more than 2 unlicensed vehicles sha'l 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.
18.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
19.) Maximum lot coverage:is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
20.) The building height is not to exceed 35 feet.
21.) Minimum setback from Lillian Street right-of-way shall be 20 feet. Minimum side and rear
yard setbacks shall be 5 feet.
22.) 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.
4111
23.) Lighting fixtures shall be desi:d 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.
24.) An address of 60 Lillian Street, Port Hadlock has been assigned to the parcel. Lillian
Street is a county local access (C534009).
25.) The lots were created through the Olson's Addition to Irondale on August 27, 1910.
26.) The parcel is served by the Quimper public water system.
27.) A septic permit(SEP90-0359) was finaled on December 7, 1990. A building permit
(BLD10-00094) fora demolition of a manufactured home will be issued with the
replacement manufactured home.
28.) 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.
01/19/2010 10:49 3603794451. JEFF CO PERMITCEN. PAGE 01/01
.XACIZ WESTERMAN III .Irifhr%en Cannily Courthouse
ASSESSOR Po Box I'x0. Pore Townsend.WA 98304
(360)345.9105
MOBILE HOME INFORMATION FORM
OWNERS NAME/MAILING ADDRESS:
NAME: fir/2% 421_ 11t c,�'�/-A 1,i,o x r�;
ADDRESS: (.('` i,Z/;i4, L57. /lip/,ft)(, .f/) 1/%fl .(1c ':".`1..5
PHONE NO. .-3 -,(''-7 t -'iG-l2
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. 'Mimi 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.
nmontirAra DOME DATA:
(A) MAKE 4'6TCA„ (a)MODEL/ M - 6 9f C"7 (C)YEAH 2._( /Zs
(I)) LENGTH 7. ... (E) WIDTH AFi (F) SERIAL # 3 _`. - 7_I
(G) YOftllt PURCHASE PRICE(Do not indnde sales tax)`/•S, 6'(2; 1''6 PURCHASE DATE,V2ain)
2) PUEVIOXIS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) molt WHOM DID YOU PURCHASE MOBILE _ .
ADDRESS
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No
PS Yes. Previous address of mobile.
It No., Wl.at County was Mobile assessed in last year.
3►WDERE MOBILE DOME IS TO 1113 LOCATED:
(A)WILL THE MOBILE ROME BE IN MOBILE HOME PARE? Yes ( No
(0)IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Spate #
(C) IF NOT LOCATED IN MOILILL DOME PARK:
NAME OF LAND OWNER: A Css`'3Z°7 q4 11/Lik, } ` 'd__..
LOCATION ADDRESS ACC) 1/f Si ('J/-bzio0 t1 in g1c4'3 2
REAL PROPERTY PARCEL #/DESCRIPTION g'Jc ,i/C'
CV j'
ij,Li Y,. t,,z
Sgnainre id 4phiant,
THANK YOU FOR YOUR DELP!
Lnnraiee Kieft'. Property Technician
N
•
09, •
O
•
•
26'-8"
13'-4" I 13'-4"
r - 46x5ev
i
4 7:5
1
1 Q w
w1D �
a v
w I
30 o I,r:w41 Fi
i , �, . L__ I=CltrACC)
fi
N
3 r NI N F n
I .
t .
44
V 1: :. " 1: .
ili
• •
cn
4.
L J
I
f
e
F
! , • 161.46' 1.1
Res area
drainfield
North
85.42' scale 1" =25'
sew
Mko1ver
A
We) Home g
24X92 162.15'
Toie
teirtibb
wwred
4x4 landing J rywell
--_-� L ! v
URM
42.01' —OP"' -
Existing
Proposed Mb I
Manufactured
Home
28x69 I 50.00' MP-
162.85' 4X4 landing
I I
•
I
, as.tu•
J
ExLsting
ddveway
48.61' I I2
X46
I I
water
meter
v 1R1
60 Lillian St
Johnson, Robert & Maureen Buy-Rite Homes
60 Lillian St Chimcum 259403 Hwy 101 Sequim
Parcel 978300104 360-681-0777 fax
360-681-0780
APPROVED c/o_H-rdi rbaugh
SITE PLAN P\s
StoRnat
APR 15 2010 Re4' JUFUUSUN GUONIY OCC
MAR 2 2 2010
J ER (> 7Y
DEPT.OF O OP E T
SIGNATU :
��45C�N c0& JEFFERSON CNTY •
w ' \>� } DEPARTMENT OF COMMUNITY DEVELOPMENT
"' '� 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
" O� www.co.jefferson.wa.us/commdevelopment
,..,llso,
1SBIN6'.
Master Permit Application MLA: V9 10 I
Project Description(include separate sheets as necessary):
TA- 5In////WI G' /l qA L/�I .0 LtL/J er //04,-c--
Tax Parcel I Property
Number: el7rq-.--5('}o jm'I Size: 2 G bp Z_ (acres/(ivare feet)
Site Address and/or Directions to Property:
66 `////./,L/ 7 ' ('://mm i/re a di ) �./ 9�'�zs'
Property Owner(s)of Record: A-4,567 7 ,r,.' /1),L1e1,r'C �tl� ,(C1r/.cJ_ �1
Telephone: l(o()- ter` - yev2 ( Fax: email:
Mailing Address: UG / ,,(/HA) ,:_.:-./ (1/(;;(/feL/ii) Z /) 914'12`.)
Applicant/Agent(if different from owner): . Luy-/'7.C'"---,0"),,r S !/0 1//,<V, 4<'/-_-2--)ei.'/7
Telephone: .':))(Q(:)-('i -C77 7 Fax:3l O- ‘, I- 67,C( email: (lirdi40 1 0.7-h%t�j-tbfru=u,['o ,i
Mailing Address:7)r 'i'` ,1/i,"y Jo/ •` ./ vu irr.) /a 41 g? h•'2.
What kind of Permit?(Check each box that applies
)Building 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
❑Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
XManufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
0 Commercial* 0 Boundary Line Adjustment
0 Change of Use 0 Short Plat**
❑ Address 0 Road Approach ❑ Binding Site Plan**
O Home Business 0 Cottagelndustry ❑ Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
O Sign 0 Plat Vacation/Alteration**
0 Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
O 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/L /-/i 7c iItur s ,'/d >��)/,'cl, to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE: ��' -� Date:c73—�CJ -/
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 apct on that he or she wants prior notice.
Signature: V/,/, 4,'z. /./11,; j,, -a-/�/ Date: � j� )/, G %G'
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 isstyed 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 nori-transfe{Qble responsibi ty for adhering to and complying with the ESA. The Applicant has read this disclaimer nd signs and dates it below.
i Signature: ) .�.�i - (, 6 t Date: ,> 'y/C)
::\Documents and Settings\carol\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc
0 BUILDER STATEMENT III
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:
GENNRAL CON1RACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
/)ic(/-A.ii(' //)/7Lt,`1 (-�(r'i))6n((.I- 0%7 7 (l-rill) 681 -o l?(�
MAILIN ADDRESS: l c)6/ L/(L.'J� >//6i'y/4)/ -.7e,1 2f?l l EMAIL: I ir.�I Qcd buy-F 1"le_itOIr1F S. 06r11
CONTRACTOR'S LICENSE QQ WAINS /� C
NUMBER: f ��yA,ri l riegc,e.f 6 NUMBER tC'/l4 SOCSL
ARCHITECT/ENGINEER: 7 PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New X Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: 1 Bank ❑ Community System
Ci Alteration/Remodel ❑ Concrete Total: Height: X Individual System❑ Repair ❑ Masonry SEP Permit# it..)"39
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ! Two Party
Type of Heat: Proposed: - )4, Public
7 C ;., 14, Total: Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
❑Underground Tank °Above ground Tank Size of Propane Tank:
❑Heat Stove 0 Cook Stove 0 Woodstove ❑ Fireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH BId App Review: rt7Y—
2nd Floor Heated Consistency Review: 24"3'
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement Plan Check fee: _
Unheated Basement State Surcharge fee:
Other Unheated ''' ' 2 Pot Water Review fee:
�
Garage/Carport SUBTOTAL
LO.Sr
Decks 911/Rd Approach fee:
Other TOTAL: $I-.,
Receipt Number: ' t 4� ,
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: yy
.Fair market value of all labor and materials foundation to finish 3-Zz I o
Initials: —� —lam
C:\Documents and Settings\carat\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc