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Home My WebLink AboutBLD2010-00277 •BUILDING PERMIT APPLIC•ON MLA10-0 Review Type:pe: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD10-00277 Received Date: 8/2/2010 SITE ADDRESS: THORNDYKE RD OWNER: DANIEL A IVERSON TRUSTEE PHONE: JEAN E IVERSON TRUSTEE 144 RAINBOW DR#4460 LIVINGSTON TX 77399-1044 TRAILS END HOMESITES SUBDIVISION: Block: 3 Lot 21 PARCEL NUMBER: 950100320 Section: 16 Township: 27 N Range: 01 E CONTRACTOR: SOUTH SHORE CONSTRUCTION PHONE: (360) 275-0818 230 E HILLSIDE DR BELFAIR WA 98528 Contractor's License SOUTHSC016NL Expires 3/13/2012 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW GARAGE ATTACHED TO M/H TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 23,000.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: 576 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: 0 Exist: Prop: 0 rop: 0 Total: 0 Total: 0 Routing Date: Ili -2:10 Type Amount Paid By: Date: Receipt: Approved/Date Permit $363.25 LYK 08/02/10 119865 APPROVED Plan Check $236.11 LYK 08/02/10 119865 State Building Code $4.50 LYK 08/02/10 119865 20 10 Total: $603.86 NOV Jefferson County Planning Building Department Jefferson County Building 13.sion Permit Nu, : BLD10-00277 Applicant: IVERSON TRUSTEE BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2009 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 . Minimum setback from Thorndyke Road right-of-way shall be 20 feet. Minimum north and south property line setbacks shall be 5 feet. Minimum setback from top of landslide hazard area bank shall be 20 feet. Erosion Control SEE CONDITION 3 Post Holes Foundation Footing 11. _ ,6 - r Footing Drains Foundation Stem Wall L2-i*'16 \ Yl Underground Plumbing Straps(hold downs) Ext. Shear Wall Nailing Rough-in Plumbing Framing t`24 J(( 'W J Blocking Wallboard Nailing Drywell/Alt Drainage SEE CONDITION 1 &2-SWT&GEOTECH CERTIFICATION PRIOR TO FINAL Address Posted So (owl' I.+ FAN -JD hip FINAL INSPECTION /2[/1" 11 FINAL INSPECTION M S BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR • • CONDITIONS for Building Permit# :BLD10-00277 1.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT AN ORIGINAL WRITTEN WET-STAMPED LETTER FROM ENVIROTECH ENGINEERING STATING THAT THE STORMWATER FACILITY HAS BEEN CONSTRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE "DRAINAGE FACILITY" LETTER DATED oCTOBER 20, 1010 AS SIGNED BY MICHAEL STRATON, P.E. OF ENVIROTECH ENGINEERING. 2.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT AN ORIGINAL WRITTEN LETTER FROM ENVIROTECH ENGINEERING WHO PREPARED THE GEOTECHNICAL REPORT DATED JULY 21, 2010 STATING THAT THE STRUCTURE AND/OR FACILITIES HAVE BEEN CONSTRUCTED IN CONFORMANCE WITH THE REQUIREMENTS OF THE "GEOTECHNICAL REPORT." THE LETTER SHALL BE WET-STAMPED BY THE LICENSED GEOLOGIST/ENGINEER. 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.) Water line must maintain 10' min. setback from any portion of the septic system. 5.) 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. 6.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 7.) A vegetative buffer of 20-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 8.) A Geotechnical Report dated July 21, 2010 prepared by Envirotech Engineering was submitted in conjunction with this application. The report addressed the stability of the geologic hazard area. A setback of 20-feet shall be measured perpendicularly from the top or toe of the geologic hazard to the proposed development. 9.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC) Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 10.) Prior to and during approved coniktion activities, the perimeter of the landsiazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 11.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 12.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or any other prominent physical marking approved by the UDC Administrator. 13.) 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. 14.) 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. 15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 16.) 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. 17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. Pre-existing legal lots of record less than one acre in size in rural residential districts are subject to the stormwater requirements in Chapter 18.30 JCC and must meet the "Area of Impervious Surface Coverage"to the maximum extent practicable as determined by the administrator. Lot coverage is defined as amount of impervious surface, which includes rooftops, driveways, concrete, etc. 18.) The building height is not to exceed 35 feet. 19.) Minimum setback from Thorndyke Road right-of-way shall be 20 feet. Minimum north and south property line setbacks shall be 5 feet. Minimum setback from top of landslide hazard area bank shall be 20 feet. 20.) 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. 21.) 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. • &vt,v'voted/ Ewg ,eertik 9 Geotecrvaocii ° EfA.vt,rowvvtewt0 ° °t2.oadwau January 10, 2011 South Shore Construction 230 E.Hillside Drive Belfair,Washington 98528 RE: Foundation Assessment for Daniel and Jean Iverson Structure Located along Thomdyke Road, Parcel 950-100-320/950-100-321,Port Ludlow,Washington Dear Mr. Moore, Envirotech Engineering (Envirotech) has completed this foundation assessment letter for a residential structure located on the referenced property. Envirotech completed one site visit after pin piles were installed, reinforcement steel assembled, and concrete in place. Information pertaining to the project was provided by Rich Moore of South Shore Construction. The pin piles were not required for structural bearing, but were utilized as slope stability mitigation. The pin piles are 2-inch diameter, schedule 40 steel pipe. Each pin pile was driven per the recommendations provided by Envirotech in a geotechnical report dated July 21, 2010. Per the information provided by the contractor, and site observations by Envirotech, the pin piles are suitable for this project and intended application. As previously mentioned,pin piles are only required for slope failure mitigation. If slope failure occurs, long-term integrity of the pin piles may be compromised, and the site must be re-evaluated for further mitigation by a professional engineer. Envirotech appreciates the opportunity to be of assistance on this project. Please contact Michael Staten at 360-275-9374 if you have any questions or require additional information. Sincerely, Envirotech Engineering bg , CLYpE Sr �G4 Gov wnsy��c Y�`t2 i ` 7 Ail ifipl14 ,) w� CISTE043045 a RE C 1� � O F �4 S�pNAL„AG`� Michael Staten, P.E. JAN 18 .2011 . Project Director JEFFERSON CUUND, PO gox_984 -geLfair, washi,vt.atow 98528 off: 36O-2755-9374 CeLL: 360-689-6045 Fax: 360-275`47 8.9 evt.vLrotech@aeotechwicaLCw facow, • III r► -?9 EVLvirotech &ydswueert,o,e 6,eotechv Ic.cL ° Evuvl,rovUMevttaL °Dr01,1442ee ° R.oadwaT October 20, 2010 UC South Shore Construction Daniel and Jean Iverson 1545 Thomdyke Road Port Ludlow,Washington 98365 ( Reference: Small Parcel Stormwater Management Plan for the Property Located on Thomdyke Road \ Parcel 950-100-320 and 950-100-321, Port Ludlow,Washington Dear Mr. and Mrs. Iverson, Envirotech Engineering has previously completed a geotechnical report, and the enclosed small parcel stormwater management plan for the referenced property. The drainage design was based on the 2005 Department of Ecology Stormwater Manual for downspout infiltration systems. Based on the proposed 2,256 sf of roof area, 135 sf of available infiltration area, and on-site fine and medium sands, drain rock depth should be at least 3 feet in depth. This conclusion was interpolated from a standard trench width of 2 feet,and a trench length between 30 If(medium sands)and 75 If(fine sands)for every 1000 sf of roof area. Per the geotechnical report, downspout runoff should not be located within 30 feet of the critical slope. Although an overflow system at the roof downspout may be located on the west side of the residence, overflow is not permitted on the east side of the structure. Therefore, it is recommended to utilize an overflow pipe at the infiltration pit. We conclude that the drainage design is acceptable with relation to the geotechnical report, prepared by Envirotech Engineering on July 21, 2010. Envirotech appreciates the opportunity to be of assistance on this project. We anticipate that this small parcel stormwater management plan meets your expectations. Please contact Michael Staten at 360-275- 9374 if you have any questions or require additional information. Sincerely, Envirotech Engineering CLYDE 07 ov WA Sy!ST-9,i, .rj r /O/20//O �9x, RF�S R�° ``w APPROVED ASS/ONAL ps STORM WATER PLAN Michael Staten, P.E. Project Director NOV — 3 2010 74 NE Hurd Road Fel.-fa.r, wa.chCvuc tovn.98528 JEFFERS OU of: 300-2775-9374 DEPT.OF CO , ITY DE E. EN Cell: 300-08 6045 SIGNATU' .. /1i,\..40, a' Fax: 300-275-4789 di • evt.vLroteck@eieotechvu,caLLvLfo.coon. • • OVERFLOW PIPE AT INFILTRATION AREA PREFERRED OVER DOWNSPOUT OVERFLOW HOUS\� /—ROOF DRAIN r I ERFLOW SOLID LID GROUND SPLASH BLOCK SURFACE BACKFILL 4' DIA. MIN PERFORATED PVC PIPE 2% MIN ENCOMPASS ,= _ 2i MIN DRAINROCK WITH .x t 6, MIN FILTER FABRIC +w`Y 4' DIA MI -Wr Y -� SOLID PVC FINE MESH SCREEN 4' DIA. MIN, . . . ... CATCH BASIN SOLID PVC 3/4' - 1 1/2' � �, �Y•• SUMP WASHED DRAIN + .+ Y+ "+ �� ROCK ........•... 3' MIN 'Artiratirip AWAY 15 FT ION � �, -, 25' �Y: i�*?9 ntrl�i ROOF DRAINAGE DETAILS _ N.T.S. INFILTRATION SURFACE AREA TO BE 135 SF Voti CLYOe NOTES. `�►� �F AS Ix 1.1. INFILTRATION AREA TO BE LOCATED ON THE SOUTHWEST CORNER OF -\7PROPERTY, AS SHOWN ON THE SITE PLAN. rt 40 401 2. DRAINAGE SYSTEM FOR ROOF RUNOFF SHALL BE INSPECTED BY HOME .-t OWNER BI-ANNUALLY, AND MAINTAINED AS NECESSARY. Oa /A9 • IFS�0NAE GiST C,V. APPROVED STORM WATER PLAN PROJECT/ OWNER/ LOCATION. SMALL PARCEL STEJRMWATER NOV - 3 2010 MANAGEMENT PLAN IVERSON THORNDYKE ROAD PARCEL 950-100-320 I. 950-100-321 JEFFERS OU PORT LUDLOW, WASHINGTON DEPT.OF ITY DF :LO MENT ENGINEER. ENVIROTECH ENGINEERING SIGNATURE: 74 NE HURD ROAD BELFAIR, WASHINGTON 98528 360-275-9374 DRAINAGE DETAILS • ;Cr N ► 4040 3068 ♦ a) w 0 c L c co a ov x 3 cD o N 0 0 COr 0) •• E (0 IL x N w 0 co' a A = r (0 \/ O x J o ' Z II o a Q CL Z w J 0>x;' 2 • • BMP C105: Stabilized Construction Entrance Purpose Construction entrances are stabilized to reduce the amount of sediment transported onto paved roads by vehicles or equipment by constructing a stabilized pad of quarry spalls at entrances to construction sites. Conditions of Use 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. On large commercial,highway,and road projects,the designer should include enough extra materials in the contract to allow for additional stabilized entrances not shown in the initial Construction SWPPP. It is difficult to determine exactly where access to these projects will take place; additional materials will enable the contractor to install them where needed. Design and • See Figure 4.2 for details.Note:the 100'minimum length of the Installation entrance shall be reduced to the maximum practicable size when the Specifications size or configuration of the site does not allow the full leng th(100'). • A separation geotextile shall be placed under the spalls to prevent fine sediment from pumping up into the rock pad. The geotextile shall meet the following standards: Grab Tensile Strength (ASTM D4751) 200 psi min. Grab Tensile Elongation(ASTM D4632) 30%max. Mullen Burst Strength (ASTM D3786-80a) 400 psi min. AOS (ASTM D4751) 20-45(U.S. standard sieve size) • Consider early installation of the first lift of asphalt in areas that will paved;this can be used as a stabilized entrance. Also consider the installation of excess concrete as a stabilized entrance. During large concrete pours, excess concrete is often available for this purpose. • Hog fuel (wood-based mulch)may be substituted for or combined with quarry spalls in areas that will not be used for permanent roads. Hog fuel is generally less effective at stabilizing construction entrances and should be used only at sites where the amount of traffic is very limited. Hog fuel is not recommended for entrance stabilization in urban areas. The effectiveness of hog fuel is highly variable and it generally requires more maintenance than quarry spalls. The inspector may at any time require the use of quarry spalls if the hog fuel is not preventing sediment from being tracked onto pavement or if the hog fuel is being carried onto pavement. Hog fuel is prohibited in permanent roadbeds because organics in the subgrade soils cause degradation of the subgrade support over time. • Fencing(see BMPs C103 and C104)shall be installed as necessary to restrict traffic to the construction entrance. 4-8 Volume II— Construction Stormwater Pollution Prevention February 2005 • • Whenever possible,the entrance shall be constructed on a firm, compacted subgrade. This can substantially increase the effectiveness of the pad and reduce the need for maintenance. Maintenance • Quarry spalls(or hog fuel)shall be added if the pad is no longer in Standards accordance with the specifications. • lithe entrance is not preventing sediment from being tracked onto pavement,then alternative measures to keep the streets free of sediment shall be used. This may include street sweeping, an increase in the dimensions of the entrance,or the installation of a wheel wash. • 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 site. The pavement shall not be cleaned by washing down the street,except when sweeping is ineffective and there is a threat to public safety. If it is necessary to wash the streets,the construction of a small sump shall be considered. The sediment would then be washed into the sump where it can be controlled. • Any quarry spalls that are loosened from the pad,which end up on the roadway shall be removed immediately. • If vehicles are entering or exiting the site at points other than the construction entrance(s),fencing(see BMPs C103 and C104)shall be installed to control traffic. • Upon project completion and site stabilization, all construction accesses intended as permanent access for maintenance shall be permanently stabilized. Driveway steal meet the requirements of the Pe gyp agency It Is recommended that the entrance be crowned so that nrwn voreco drains off the pod `t, Instal driveway culvert � If there Is a roadside • 1-'••'• ditch present •'•p:i:, 4'-8'Way spells GeomxOle CC.‘ � t r mN,tttcloress_�• �S �� Provide lull width of krpress/egress area Figure 4.2—Stabilized Construction Entrance February 2005 Volume ll-Construction Stormwater Pollution Prevention 4-9 III I oN o }{}aGht?d GQYGIO�e �4� ° JEFFERSON COUNTY `J 4 / DEPARTMENT OP COMMUNITY DEVELOPMENT f40621 Sheridan Street• Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax $�S,�NO,sO$ www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: ( 0 -aCV Project Descri tion(include separate sheets @s necessary): gulidiril a-{+a.chec qa,u-a 1, - o 'H Tax Parcel Number:`,50/D 0 32 0/ w1�O/OD 3 2 I ProperlySize: (acres/square feet) Site Address and/or Directions to Property: TAM VIC kw ROAc1) - A-Lucl low, W A ci$34? Property Owner(s)of Record: --Oa-VIi -1 3 -cir\ :veers or Telephone: O S'O '-�-2-/3 Fax: 3� email: 'f Mailing Address: 272o E - H i I(S;(762- TA-- ) 1-C"a;r t, P. `Rcg5 2% Applicant/Agent(if different from owner): S°u1{i Shore, (arts-i'yI{c.i V I I V'G. Telephone:3(00 - 509- /342_ Fax: 3(00-2-75-(0256 email: -- Mailing Address: 23 D j✓H i/($1 c) 13e I-Fn,i t w A 01 8 5`1.% What kind of Permit?(Check each box that applies uilding Critical Areas Stewardship Plan ]�B El Demolition Permit ❑Variance(Minor,Major or Reasonable Economic Use) ❑Single Family ,Garage 4 . -:j Detached 0 Conditional Use[C(a),C(d),or C]** ❑ Manufactured Home El Modular 0 Discretionary"D"or Unnamed Use Classification ❑ Commercial* ❑Special Use(Essential Public Facilities)** ❑ Change of Use ❑Boundary Line Adjustment ❑ Address 0 Road Approach ❑Short Plat** ❑Home Business 0 Cottage Industry ❑Binding Site Plan** AUG - 2 ❑Propane 0 Long Plat** ❑Sign ❑Planned Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes'Use Consistency Analysis ❑Plat Vacation/Alteration** ❑Stormwater Management El Shoreline Master Program Exemption/Permit Revisions** ❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development*"` ❑Temporary Use 0 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 ❑Tree Vegetation Request **Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal,if known: Ara DESIGNATION OF AGENT I hereby designate b t .:%(Q,, h f 11/ � ��WU-��11/ hG to ct as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: O 7-2- oG—IV 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 attomey's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she wants prior otice. ''ll• Signature: 'IAA (2 mQ� (&d\ SS C)?Date: � O� /v ter. The action .r. tions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered •-cies 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 responsibility for adhering to and complying with the ESA. The Applicant has read this disclaim and s ns and dates it below. signature: �Yo p. i o ��'� J SS C." Date: r/ l G:\PemtitCenter\###WORMS###\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: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: SDI' SYkOVe CO Y hUC\Cn , InC. (3140) STA-1342 (itco) 275.4021.0 MAILING ADDRESS: 230 E. '-'inside "(Wive_ EMAIL: --- CONTRACTOR'S LICENSE `� i r/\f IN_ q$5 25K, WAINS NUMBER: SOUT14SC0 Ijo NIL NUMBER . _ ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: ' EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New X Wood Existing: 6 1) L I Sewer ❑ Addition f] Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel Ll Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ] Private well ❑ Two Party Type of Heat: Proposed: ❑ Public MN►� 4 I 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: 1 Underground Tank 1 Above ground Tank Size of Propane Tank: 1 Heat Stove 1 Cook Stove I Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 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 Forlffic0 Use%Only ;s ,,,., , Amount Revision ;- t 4- Main Floor Heated r r = EH Bld App Review: Iiie u f1 - 27 Floor Heated • '� ` Consistency Review: Af. Other Heated , Base fee: Cs ,P5 Mezzanine -w Additional Section: _`_ ,,,]; - _. Heated Basement Plan Check fee: ) _• I I Unheated Basement State Surcharge fee: ,.L 50 Other Unheated Pot Water Review fee: 1 �6 PL 1P I`J Garage/Carport SUBTOTAL Decks M 111911/Rd Approach fee: ft J p/� . .: TOTAL: $ (0ya- Other 81O f Receipt Number: 1 19 Ws' CashlCheck Number: 82, 3 ESTIMATED COST UIRED) Date: C —�G� .Fair market value I l rend materials foundat:o finish --H� irl Z000 Initials: l r G:\PcrmitCcnter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc N. O oo y ;. m Z \ 1 CS' (o -ilk W m ° w `�° c �. o mil �d�. 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