HomeMy WebLinkAboutBLD2011-00011 BUILDING PERMIT APPLICAIN MReiew Type:I
000 12
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00011 Received Date: 1/18/2011
SITE ADDRESS: 313782 HWY 101
BRINNON, 98320
OWNER: LARRY L HOWE TRUSTEE PHONE:480-722-9779
LARRY L HOWE REV LIV TRST
14548 SE 51ST ST
BELLEVUE WA 98006-3510
SUBDIVISION: Block: Lot: TX 67
PARCEL NUMBER: 502311020 Section: 31 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 1,232
CODE EDITION: 2009 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: 1PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 01/18/11 58423 'P P R®\V/E r
Potable Water Application $62.00 LYK 01/18/11 58423
L
Total: $275.00 MAR �� Lt911
,sefferson County Plannin,
& Building Department
MANUFACJRED/MOBILE HOME INSTA!LATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00011 Received Date: 1/18/2011
SITE ADDRESS: 313782 HWY 101 Issue Date: 3/17/2011
BRINNON, 98320
APPLICANT: LARRY L HOWE TRUSTEE
LARRY L HOWE REV LIV TRST
14548 SE 51ST ST
BELLEVUE WA 98006-3510
SUBDIVISION: Block: Lot: TX 67
PARCEL#: 502311020 Section: 31 Township: 25 N Range: 02 W
CONTRACTOR/ OWNER/BUILDER PHONE:
DEALER
PROJECT DESCRIPTION: MANUFACTURED HOME -SER#GDSTOR419114438
MAKE: GUERDON YEAR: 1992 SIZE: 44X28
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
Erosion Control
MH Foundation
Blocking&Tie Down
Skirting&Ventilation
Gas Line: Exterior
Propane Tank
Pressure Test
Drywell/Alt Drainage
Address Posted
f � ..CL 1-f2 Rot_ ~fr) .4-vu
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY- SEE REVERSE
HOWE BLD11-11
313782 HWY 101 MLA 11-12
v�� U
• •
SPECIAL CONDITIONS CASE # BLD11-00011
1.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT A WRITTEN
LETTER FROM THE GEOLOGIST WHO PREPARED THE GEOTECHNICAL REPORT
DATED FEBRUARY 11, 2008 STATING THAT THE STRUCTURE AND/OR FACILITIES
HAVE BEEN CONSTRUCTED IN CONFORMANCE WITH THE REQUIREMENTS OF
THE "GEOTECHNICAL REPORT." THE LETTER SHALL BE STAMPED BY THE
LICENSED GEOLOGIST/ENGINEER.
2.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT A WRITTEN
LETTER FROM STRATUM GROUP STATING THE STORMWATER FACILITY HAS
BEEN CONSTRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE
"STORMWATER DISPERSION" LETTER DATED FEBRUARY 24, 2011 AS SIGNED BY
DANIEL MCSHANE OF STRATUM GROUP.
3.) The application was reviewed by the Jefferson County Department of Community
Development staff on February 16, 2011 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, the following ESAs were
confirmed to be present on the subject property: Shoreline Designation: Conservancy,
Shoreline Slope Stability: Unstable, Spotted Owl Habitat, Wetlands (mapped at shoreline),
Landslide Hazard Area: Slight& Moderate, Susceptible Aquifer Recharge Protection Area
(SUSC), Coastal Seawater Intrusion Protection Zone (SIPZ).
4.) 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.
5.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
6.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within 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.
7.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
8.) 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.
9.) The parcel is located within a Altai SIPZ (seawater intrusion protection z4Daccording
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.
10.) 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.
11.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
12.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
13.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
14.) A Geotechnical Report was submitted in conjunction with this application. The report
addressed the stability of the geologic hazard area. A setback of 30-feet shall be
measured perpendicularly from the top or toe of the geologic hazard to the proposed
manufactured home.
15.) 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.
16.) Prior to and during approved construction activities, the perimeter of the landslide hazard
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."
17.) All construction activities shall not encroach upon the landslide hazard buffer. This
includes the storage or preparation of materials.
18.) 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.
19.) Critical Aquifer Recharge Are/bay require special protection measures to gate water
quality degradation. The submitted proposal does not require additional aqui er
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.
20.) The applicant is proposing to create or add 1,250 square feet of impervious surface and
2,500 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.
21.) The project shall adhere to the Best Management Practices (BMPs) 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.
22.) 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).
23.) The revised site plan as submitted on March 14, 2011 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 March 17, 2011 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
24.) This approval is for a 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.
25.) The parcel has been designated as Rural Residential 1:5 under the Jefferson County
Comprehensive Land Use Map effective August 28, 1998.
26.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
27.) 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.
28.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
29.) The building height is not to exceed 35 feet.
30.) Setback from Highway 101 right-of-way is no less than 50 ft., side and rear setbacks are
no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more
restrictive setback shall apply.
31.) 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.
32.) 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.
33.) NOTICE: This permit does noSuse the proponent from complying with cco 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.
JACK WESTERMAN HI • Jefferson Count'.Tourthouse
ASSESSOR PO Box 1220, Port Townsend, WA 98368
(360) :385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: .17A-14' Oft'a:111 A-C, c:, u +{o 40%1 t�
ADDRESS:_ 3� 3 ") $2 o a ! 11, a uuts.t.► w A 32a
PRONE NO. 3`3 --7 4
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 thir?'eoUu*y. another area.
I)MOBILE HOME DATA: AN 1 3 all
(A) MAKE (B) MODEL +.fr 44:11F►R C1 .
(0) LENGTH 4.1 V f (E) WIDTH Z / (F) SERIAL#G.DSqtt,iZ q lc/ if4 14.E
(G) YOUR PURCHASE PRICE (Do not include sales tax) I b0 PURCHASE DATE
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE G J R. A
ADDRESS . t41L:2 STD-cl�ac t L✓f
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes 414411
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year. N a Its is (A. LiA-
3►WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes
(B►IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Space #
(C) IF NOT LOCATED IN MOBILE HOME PARK:
NAME OF LAND OWNER: ta,
LOCATION ADDRESS Z 3� � 'Psi% ( �:1J15�, Vv fl g�3
REAL PROPERTY PARCEL #/DESCRIPTION
?.3iac) 21:4t12.-
n a of applicant
THANK YOU FOR YOUR HELP!
Lauralee Kiesel, Property Technician
STRATUM GROUP
P.O. Box 2546, Bellingham, WA 98227 APPROVED
Phone(360)714-9409
STORMWATER PLAN
February 24, 2011
MAR 1 7 .2-01
Larry Howe
1705 W Gunstock Loop
Chandler, AZ 85286 RSON
DEPT OF C FE.`
SIGNATURE:
Re: Stormwater Dispersion
313782 Highway 101, Parcel 502311020
Brinnon, WA
Dear Mr. Howe:
In my geology hazard assessment I recommend that roof run off from the home be directed into a
dispersion/infiltration trench located to the east of the home. An infiltration trench or dry well
located to the east of the proposed home will be an acceptable method of infiltrating the
stormwater. I denoted on your site plan the location of the infiltration trench or drywell. The site
plan submitted to the County had indicated that these structures were retention structures. Typical
infiltration trench or dry well plans are attached to this letter.
Using a dry well or a dispersion/infiltration trench is consistent as indicated on the attached site
plan and is consistent with my recommendations for the site. Stormwater should readily infiltrate
at the site proposed and will not have a negative impact to the slopes on or off of the subject
property.
Best of luck on your project. Stratum Group appreciates the opportunity to be of service to you.
Should you have any questions please contact our office at (360) 714-9409.
Sincerely yours,
Stratum Group • 4144
• ,�,'
L
Dan McShane, M.S., L.E.G.
Licensed Engineering Geologist 1 ; ar• PERMIT # II'
JEFFERSON COUNTY 0
-�j It l r �1'1'i) C�
-
I
°114
�,i, 0, JEFFERSON COUNTY
w . ' DEPARTMENT OF COMMUNITY DEVELOPMENT
'') 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment •
Cs
Master Permit Application MLA: 1 l 1-2-
Project Description(include separateo sheets as necessary):
d,Vs;w ATv
L. Q a c- `A m w IA o_c_r _,_r a fl_ i-So'M 4. _
Tax Parcel Number: S c.• J i O z. ) Property Size:j iAe-R-yS: (acres/square feet)
Site Address and/or Directions to Property:
I 1 -) 4J , t '1 1 es 1 `'ta42 i 4`w 4' i t r fl . 9 c .c-.
Property Owner(s)of Record: L.sl iZ�L 1 1111‘.4,.:4Z ilt-
Telephone:N A —7 27 —'�#") ' Fax:-f W.'•:7-2. c7 11 / email:L L If4+3/.49 P 4 04.44 PlitiOf
Mailing Address: % 1 off i.v' : e�..Si^% L 1.carsi't� l;ti.414 i1 l G :ZTs:) 14-z. � 2�L i-,
Applicant/Agent(if different from owner): �1
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies ❑Lot or Road Segregation
( Building 0 Critical Areas Stewardship Plan
l'0 Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Single Family 0 Garage Attached/Detached ❑Conditional Use[C(a),C(•. •r **
NManufactured Home. . .0 Modular ' . •� ❑ Discretionary"D"or Unna h7 iti( I� aa i�4r
Commercial* ❑Special Use(Essential Pu• c ace sties)**
❑ Change of Use ❑Boundary Line Adjustment
❑ Address 0 Road Approach ❑Short Plat** JAN $ 2011
rl Horne Business ❑Cottage Industry ❑Binding Site Plan**
❑ Propane 0 Long Plat**
❑Sign - 0 Planned Rural Residential Dev9Ip meet PRRD/Amendments**
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration" r � nrn
❑ Stormwater Management 0 Shoreline Master Program emp I e I isTh?i
❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development**
0 Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium ❑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` At k Pc u 6 i to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE f— ' ` ;l'"4"'E Date: I 13 �j /Z�,/ c
c S _
By signing this application f ,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. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the application thaTe or she warpts,pri r notice.
Signature: l l� i._�; JI ev Date: /2:f c3 / .ems j
The action or actions A icant 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 riot 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 resp sibility for, heyjng to and complying with the ESA. The Applicant has read this disclaimer and /'2 .
ns and dates it below.
Signature: c / x�r
C— -
)) LAE- Date: / Z/a ca 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 assumin h responsibi'ty f the General Contractor for the proposed project.
Signature: K Date: 12- 1 KP. 1241 i O
1
GENERAL CONTRAC OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
.)i ..k_44.„s -i-Rive.-T, r? 1 a!at..Kl,.,e• Ca �` : tc,�- (s •
3 C�ca_ '7�j�y J ( )
MAILING ADDRESS: `\ -7.S i- li'Vr iI -0 a1 A i .,+ .,ril EMAIL:aAt-KA r'f, -7-1- T2'" a Th p:L ,l, m
CONTRACTOR'S LICENSE ra WAINS
NUMBER: U 3.i G.cs a ci ? 7 l}3 O NUMBER .
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
)( New A. Wood Existing: 2. ❑ Sewer
❑ Addition R Steel Proposed: . . Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Z. Height: `iif Individual System
❑ Repair ❑ Masonry SEP Permit# C Y -3' `i
O Demolition ❑ Other: Bedrooms: WaterSupplyi
Existing: .�' Setback: '$ Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
L=Lr.� -- Total: .i 1 S 'i` Name of System: •
444414te.v,rl, l r/
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 I Above ground Tank Size of Propane Tank:
I Heat Stove 1 Cook Stove 1 Woodstove I Fireplace Insert ► 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.
-c t p�.,�' Y: A e =1;,.'"zZ '�"s Sx�"Y �e�' ''P J `s,i. 1',- s0 1
Square Footage Current Pro •sed -�yT c v ,6T.f. *b. .. , � '.., , - tA�� ',v ,, R `:,,
Main Floor Heated c. EH Bld App Review: ri5
—�
2 Floor Heated s'. `bk�4Wk Consistency Review: 21 2
Other Heated ., = Base fee: Zt> r
Mezzanine r Additional Section:
Heated Basement Plan Check fee:
Unheated Basement
' ' 7. Y, State Surcharge fee:
Other Unheated ;ef77-: Pot Water Review fee: i 00''
— t- >> SUBTOTAL
Garage/Carport
.... -itq .
Decks
911/Rd Approach fee: �xtS'f11J6�
rx
Other ' ' : TOTAL: $ 0CtC)
stir Receipt Number: 58L23
g,`mot _ ,F
Y Cash/Check Number: ,r3�
ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish
Initials: ( _--- -
-
\n_ _...r.- --\441443C/I1,11IC44.4f4F\TIDTI Cr1DAIC\r ..�111,1l E. ..\A! D........;4 e....i:,_,.«....c"Ni no a,._
1<
.marge•........ ...whot i
-NI t4 t.S -4.1 till
0--1
,As,41',al ill 15: i
I el
gl r°
4
. ...
z
I 1
1 f .
1 r
t --J ,
,
, 1V0 rit ,
, r
Jr
131
X , t--
',...
1
t
o
11
„
t*•
,
.
, I
e .
..1._. ,
' v
Yr; ,
/44 r
-i
c.,41,
---t
p_vo.et.1 .1-1,..ie In
Po ...-
1 4 X0 -1 ,
I
1 ,
1
. 1
7 t .
-..
.
-
\ • : t. Lt 101 -i47) SO t
<•• , 1(11'7 )k '°' ' f 2 42 3
Am I ;
If4t. t
01 -1-4
F .t..4 1.v.
2
'Is i —..
ca ' ie) i
• ,
X IN
, .:4 • u.
Oa *
N44.,:l.'i
, •
•.
0 -o
,....\:0 f'` c,
..---- . g ....t,
,.�-` r
. _
....--- te
.00' --
-04 rb 1 w 0
1 , !z • 4.4
i it lu,'..,J z1.101191 10 ..., -‘ t, . et.
I-ft 4 4, „ , ..1kr
tel
ei
-p .,. ,!bj I .1, .4 ,t1 . ' 4 , „a 1 o x .. _
- }�0 1 1 a
�y IS 12i:4 110 1,,,R �e , yr E"14-r �'', N
11.
is..
�. N ,Fes;: tt4,,� t�'_
•.A i hit .,ham� s,,.:'
Os r g ,�,,� w 9 j x
l */
ei ® 4 id 0ii.
j �e�- ti ,a,a`
•
• N \ I kg ,,1'.• • -.
e ,-.% . er... , ,r
._ - ,•,.., f 0 1
4.4 re , ....
, . ..... . ....., • dikt: 4,....
!' 'i. 1
t
0 • 14 441
— , ,. As/. ,C 41? "4• t VI
, "14 ,,, tic' -... N --., *.N9
, . -'---% ,coote*. 1 t1.1' 14 e \
• \..•'' ; :l' ii.. —` '
1aTo ( 1
/ ,
VC 1111111"=:".114"11. . .:-----
I -oil 3434:1,OPP14:
rat/ CA \ �� '
.. ,
1 .*. '•.. i — _
r- , ,
. 4i, ;
# � X � . 1 1
PP'
I
g .1' 1 ems- -b
it t i A
4 aIO 1 -i ,iii I * _____ ____
A►
31
$ en, -.3 71
C
— to �
Sira. t
® , . z m pay
t
s+ r`� -a _=` a z t �
i
,t .
N 'is SM ►iti r44kJt1