HomeMy WebLinkAboutBLD2011-00044 • •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00044 Received Date 2/24/2011
SITE ADDRESS: 31 FAIRMOUNT RD Issue Date 5/2/2011
PORT TOWNSEND, 98368
APPLICANT: JEFFERSON LAND TRUST PHONE: 360-379-9501
1033 LAWRENCE ST
PORT TOWNSEND WA 98368-6523
TX 64
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 902243033 Section: 24 Township: 29N Range: 02W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, JEFFERSON LAND TRUST PHONE: 360-379-9501
if different: 1033 LAWRENCE ST
PORT TOWNSEND WA 98368-6523
PROJECT DESCRIPTION: DEMO M/H, BARN & CONCRETE SLAB
Directions
To Site:
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 5/2/2012.
REQUIRED INSPECTION:
FinalApprova . r6,�0
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
I:\F_BLD_Permit_Propane.rpt 10/29/19
WILDING PERMIT APPLICATN B RDI I-00 eview e44
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00044 Received Date: 2/24/2011
SITE ADDRESS: 31 FAIRMOUNT RD
PORT TOWNSEND, 98368
OWNER: JEFFERSON LAND TRUST PHONE: 360-379-9501
1033 LAWRENCE ST
PORT TOWNSEND WA 98368-6523
SUBDIVISION: Block: Lot: TX 64
PARCEL NUMBER: 902243033 Section: 24 Township: 29 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: NORTH OLYMPIC SALMON COALITION PHONE: (360) 379
KEVIN LONG
205 B W PATISON ST
PROJECT DESCRIPTIOr DEMO M/H, BARN & CONCRETE SLAB
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2009 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Total: APPROVED
MAY oQ 2011
Jefferson County Planning
& Building Department
��. , oN 0,, JEFFERSO•OUNTY •
W 1 \� DEPARTMENT OF COMMUNITY DEVELOPMENT
�'' '•� I 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
SONG'S
p' www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: L\U YYII..A e, 1
Project Description(include separate sheets as necessary): Re ye structures,cement pads and old foundations at 31 Fairmount Rd,Port Townsend WA
be ill: 111,44 t 1(1. - _ cOYIN 01--..P aft . _
Tax Parcel ' Property
Number: 902243033, size: 2 acres (acres/square feet)
Site Address and/or Directions to Property. 31 Fairmount Rd, Port Townsend WA 98368
Property Owner(s)of Record: Jefferson Land Trust
Telephone:(360)379-9501 Fax: email: ed@saveland.org
Mailing Address: 1033 Lawrence St,Port Townsend Wa 98368
Applicant/Agent(if different from owner): North Olympic Salmon Coalition,Kevin Long
Telephone: (360)379-8051 Fax: 379-3558 email: projectmanager@nosc.org
Mailing Address: 205 B,W Patison St, Port Hadlock WA 98339
What kind of Permit?(Check each box that applies
laBuilding 0 Variance(Minor, Major or Reasonable Economic Use)
O Demolition Permit 0 Conditional Use[C(a), C(d),or C]**
❑Single Family ❑ Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home ❑ Modular ❑ Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
0 Change of Use 0 Short Plat**
❑ Address El Road Approach ❑ Binding Site Plan**
❑ Home Business ❑ Cottagelndustry 0 Long Plat**
❑ Propane ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign ❑ Plat Vacation/Alteration**
❑Allowed"Yes" Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑Shoreline Management Substantial Development**
0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
0 Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ 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 North Olympic Salmon Coalition,Kevin Long to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE < � Date: Z / 2 3/11
—
By signing this application form,the owner/agent tests 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 application that he or she wants prior notice. /
- ((
Signature: % 7
Date: �f
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 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 disclaimer and signs and dates it below.
Signature: / k /1 z>/" Date: € -(i-J-l ((
C:\Documents and Settings\caral\Local Settings\'Temporary Internet Files\OI.K86\Master Permit Application 12-19-2006.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: el1 V1--( <2.- _ Date: `}/ -)-h0
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
_! New Ix Wood Existing: 2 Sewer
Addition i Steel Proposed: Bank I Community System
I Alteration/Remodel I Concrete Total: 2 Height: F i Individual System
Repair I Masonry SEP Permit# NO SEPTIC
;/ Demolition i Other: Bedrooms: 2 Water Supply:
Existing: _ Setback: 1 i Private well i Two Party
Type of Heat: Proposed: I Public
none Total: 2 Name of System: NO WATER
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:
CI Underground Tank []Above ground Tank Size of Propane Tank:
❑Heat Stove ❑Cook Stove 0 Woodstove 0 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 Bld App Review: t�
I3 '
2"tl Floor Heated Consistency Review:
Other Heated Base fee: I�f I ✓-
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: 1 ---
Other Unheated Pot Water Review fee:
to ,.•vc l Ail()We-it...t ( -S:C 0
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $ I Li ,
Sheds—If etitk:tivtiy41S A,g s 0 Receipt Number: +2 3
77 Cash/Check Number: )OZ-7
ESTIMATED COST(REQUIRED) Date: _
'Fair mark
Initials:t value of all labor and aterials foundation to finish r-�
� /0 , D d a I- A6k,td i(+-c d✓1 (-_--- r _- .-- —
C:\Documents and Settings\carat\Local SettingsVI'emporary Internet Files\OLK86\Master Permit Application 1 - - OOG.do, __
May 02 11 03: 22p more (360) 379-8051 p, 2
A?R/25/2G'11/MON 04.01 PM ORCill FAX No. 3604916308I,
P. 002
5i. ;v`�t] ' Olympic Region Clean_fir.4genct
f N\ 29:10-B Limited Lane I\TIX"
• 0 7c., Olympia A 98502 .c a-)- SA3
4, (360).539-7610•FAX(360)�491-6308
s '�" ; PortingC7 o�te(360)4I7-1466
Demolition Permit
o RCA A/ Raymond Office(360)942-2137
��*- S f ac nr.ORCA1S.org
•
' Commercial Structure-Permit fee: $60.00-10 working day wait period
f ) Owner occupied residential dwelling-Permit fee: $35.00- Prior Notice
PROPERTY OWNER
N / Phone Old) 3 7 - Q.co I ,Email• a-ct sc�v..4.-4,o
¢•#.PAYS iv\ 4,4 y,�S•f" PPA': ( ) Mobile ( ) ��
Mailing Address: State: Zip:
(033 Z-4.4%.re--1,c e- 5-I- Rey--mocm....-.5e-.L vk t v'
36-8
Site Address: State: br
! Zip:
( .;r r44vv i- 49r _ uv-r--To cwt St.•,.�� 1.fi 1l S'.36.
DEMOLITION CONTRACTOR4'Check if same as property owner information
Business Name Phone L ) Finai].
PAX: ( )
Onsite Contact Phone; ( ) ' Mobile: ( )
FAX j ) -
IA—Ailing Address; City, State; Zip:
DEMOLITION I'NFORMA.TION . Do nv,- .S>f 4,1 f t -fey-- Kba.-5 pe, ,,les ct /t
#of Strucrres being demolished: Start Date: Completion Date:
fi 2 r,I 18 n ,
. Asbestos present XYew No Survey attached ><Yes No Has allidenufied asbestos been
removed Yes )4.No
DEMOLITION PROJECT CATEGORY
'Couaplete Demolition
[ )Training Fire-Fire Agency;
[ )Renovation,Alteration,Remodeling,Maintenance,or other Construction
`{ J Emergency-Additional Fee of$50.00(roust be accompanied by Government Ordered Declaration-Commercial on)y)-
I have read and will abide by the conditions ser forth in this permit and any addendum thereto. I do hereby certify
that zif Jde dried asbestos has been removed and the information ha this application and supplemental data
described berew is, to the best ofmy knowledge,accurate and complete.
Sov-e-t,_Sp o.,J2-44— qove..-L-L4 c.-d-L-, 3/2-1(h
Applicant Narnet Signature i Date
Date Application Received Payment Info, } Approredr"' AS+ sbestos. Permit
w�•--, (-;‘, ., 'l [ ) Cash ^ [ 1 Disapproreds • Permit.# ,1 j ASBOO
l'. r- i i.._.t Check: # d O
Demolition Pc•rmit
[ ) Credit Card Rerircr date: 3 / zir/ If ?ersait# i ( pLM00 `41 I
MtR24. Zi;,i -6')
Reccire dateLl (L Re-rimed by: • ,
y.genTAC..7.re Only .9tencj C)rt Ord) .Fen use Onl). 1 .4ZeF Use Onf>'
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DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00045 Received Date 3/1/2011
SITE ADDRESS: 970 BEE MILL RD Issue Date 7/27/2011
BRINNON, 98320
APPLICANT: SEATTLE COUNCIL PHONE: 360-796-4427
OF BOY SCOUTS OF AMERICA
PO BOX 440408
SEATTLE WA 981144408 1+
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 602131002 Section: 13 Township: 26N Range: 02W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, SEATTLE COUNCIL PHONE: 360 796 4427
if different: OF BOY SCOUTS OF AMERICA
PO BOX 440408
SEATTLE WA 981144408
PROJECT DESCRIPTION: DEMO EXISTING STORE
Directions
To Site:
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 7/27/2012.
REQUIRED INSPECTION:
FinalApproval:
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
I:\F_BLD_Permit_Propane.rpt 10/29/19
ItILDING PERMIT APPLICATN BLD11-00045
Jefferson County Department of Community Development Review Type:
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD11-00045
SITE ADDRESS: 970 BEE MILL RD Received Date: 3/1/2011
BRINNON, 98320
OWNER: SEATTLE COUNCIL
OF BOY SCOUTS OF AMERICA PHONE: 360 796 4427
PO BOX 440408
SEATTLE WA 981144408
SUBDIVISION:
PARCEL NUMBER: 602131002 Block: Lot: 1+
Section: 13 Township: 26 N Range: 02 W
CONTRACTOR: OWNER/BUILDER
PHONE:
REPRESENTATIVE:
PHONE:
PROJECT DESCRIPTIOP DEMO EXISTING STORE
TYPE OF WORK COM SQUARE FOOTAGE:
TYPE OF IMP DEM COMMERCIAL: 1,200
VALUATION MAIN: INDUSTRIAL:
CODE EDITION: 2009 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER:
CONST TYPE: GARAGE: SHORELINE:
DECK: SETBACK:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES: BANK HEIGHT:
WATER SYSTEM:
BATHROOMS:
Exist:
Prop:
Total:
l
Routing Date: —
I- ( 1
Type Amount Paid By: Date: Receipt:
Permit ?pPROV 1)
proved/Date
EA
$71.00 LYK 03/01/11 123243 6L_�
State Building Code $4.50 LYK 03/01/11 123243
Total: $75.50 JUL97 2011
Jefferson County Planning
& Building Department
avi.i LJILE111/JILIN UL:UU FM INCAA FAX No. 3604916308 P. 001
IIII
410 Olympic Region Clean Air Agency
--at
,--v.,41c4• `.;\ 2940-B Limited Lane NW
ic? /..."
%-, Olympia,WA 98302
r-il (360)539-7610•FA.X(360)491-6308
• i •
i v ..-.' 7 Port Angeles office(360)417-1466 Dernolition.Pepnit
..
-;* ORCAA it
/ Raymond Office(360)942-2137
''-tko
• tinny ORCAA.org . • . •
.
p4 Coannercisd StruCture—Permit fee: $60-00-- 10 woriOng day wait Period
[ I Owner occupied residential dwelling—Permit fee: $35.00—Prior Notice
PROPERTY OWNER• '• •
. .
Name c A•,,•ene.5.4...kfe c....444c. / 13,1-44 . Phone: .Liz 77C- vie r 7 Email. • . •11:44.-5
11011M727323" • Mobile -
• Mading-Wess: • . • ZiP City: • • State
•7e> ee tY,W .Rd' .. . . . -
*.--.iiiewt .• •
We 01- • '7483C'e)
Site A ddrese : . •
• ' • . City: State: . _ ZiP'•
.5.k.ore
5..t...‘e. . W Aft • Yt33 te,
• ... ,
• .
DEMOLITION CONTRACTOR[ 1Check iisame sts pro.- owner information
. Business Name: -
Ph otte .
Frnsil-
PAX ( )
Onsite Contact .
• n
• • orm f . ).. • ' Mobile ( , ) •
. e.4 fly c FAX • .
• Mailing Address:
City: • State Zip'
- 7e, .1. ee. -eel". za
• . ....I."-, . . . Wei raszaz.
DEMOLITION INFORMATION
. .
#of Structures being demolishect . •• •Start Date;
• .Coletion Date . • .
CAA 1682,44)e.4
g.t dic noiRadt
Asbestos present .. Yes jOslo • Sorvey attached &.. - X_No. Ras all identified-asbestos been
lacorfi---itic-re • ____ate• - ., _ - removed _Yes ..,_._ o
. DEMOUTIONPRO CATEGORY
• ' • -
ty)Complete Demolition
Co,,i 70-
. [ I Renovation,Alteration,Remodeling,Maintonance,or other Construction . .
Eme -Additional Fee of$50.00(must be ac =led, Govan mem Ordered Declaration-Commercial onl
lhare mad and WI abide.by the conditions set forth la this perrat and any addeadran thereto f da hereby cerdfr
that all identiffed ashcan's has been removed and the information in this JrppNcation and supptexneprodata
described.herein is, to the best ofiny knorviedgr,accurate andcOrnpiete. • •___ _
Ke3. Aic ---,.."),.„.4 -.0.2-7 ..,.. :, --Z S -it
Applicant Name Sigoature • I J L Date: •
Date_Kle Bfiah M gym=Info.• Approved JEFF _
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COMONITyDF M°6_,
7f - ,ASBOO;41:::heck # linC1121 '
Demolidon Permit
MAR 2 9. 20'il [ i Credit C.ard-7----. Review date: /Z9/ _ 'Permit#_LIDEMOO.Dlenc
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• ADI I Reviewed
A•.r.1! Piptgejii_Irk I Receive dinth3 _____Li br.
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j DEPARTMENT OF COMMUNITY DEVELOPMENT
rzi
'� ` `4 621 Sheridan Street• Port Townsend •Washington 98368
.4.. c.
360/379-4450 • 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
Cs
Master Permit Application MLA: 00 n1 12- 0 ui
Project Description(include separatesheets as necessary):
0 Fis't cs I,'/ O,-r C" T/ c> API C<..rt- 5 1-c,r^e
Tax Parcel Number: 6 U- / 3 / e.'C. Property Size: i etc) (acres/square feet)
Site Address and/or Directions to Property:
7?c /3ee •"4,1/ A.-(' e,, ., it w, ?S55 3
Property Owner(s)of Record: C ,' ' S C r c,'
Telephone:3cc. 776 S:c2 7 Fax: Aa -7pe- zo j t email:
Mailing Address: 7 7 v /3 e-E /Nl,// A).-
Applicant/Agent(if different from owner): Kt .-1 /k/ C&g/ ._ t lam-
Telephone:36- •_s• S I-z c= fe 6 Fax;,, email:
Mailing Address: T?c /3 N e /.1,'// ,('-(
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
uilding ❑Critical Areas Stewardship Plan
Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
❑Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a),C(d),or CJ**
❑ Manufactured Home .0 Modular - - 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)**
❑ Change of Use 0 Boundary Line Adjustment
❑ Address _0 Road Approach ElShort Plat**
❑ Home Business 0 Cottage Industry 0 Binding Site Plan**
❑ Propane 0 Long Plat**
ElSign ❑Planned Rurai 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 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 0 Tree Vegetation Request
**Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known:
OF AGENT
N
I hereby designate tt ep.-t r't Awe c �*A re-7
� >�ESIGN toTaOt as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE "i4c_.--, �� ��-� Date: Z - 5 //
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. 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 wads prior notice./-,
Signature: ,,ifie���LeL ,c�ir. Date: -Z- -3 //
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 the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility for ad ing to and c plying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: <<—G iber
Date: '�. — Z 3 -
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Perna Application 5-29-08.doc
.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 assuming the responsiblyof the General Contractor for the proposed project.
Signature: itt,i, 4refe.-.0-zei.-- Date: '----2,3 —1/
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAx:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER .
ARCHITECT/ENGINEER: PHONE ( ) FAx:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: _ Height: ❑ Individual System.._. --"
❑ Repair ❑ Masonry SEP Permit#
Demolition ❑ Other: Bedrooms: Water Supply:
Existing: 6 ___. Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: -- Public
Total - Name of System:
Cst-•+t, /.".!'�o.r 5
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: /0 c% Proposed: /e-"' Number of ADA Parking Spaces: /t)
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food SerMic Ye No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that appl
t 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. ,
Square Footage Current Proposed fgrOffice 4l r?ilt r , `, _ Amount , .; Revision
Main Floor Heated EH Bld App Review:
1 Z C)C' . LL%I ..L I.
2t'd Floor Heated Consistency Review:
Other Heated ____— Base fee: .-r I -
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Pot Water Review fee:
Other Unheated - ._--. -
Garage/Carport �- SUBTOTAL
Decks 911/Rd Approach fee: ,,__
Other TOTAL: $ j je)
Receipt Number: l '7 L;-f
Cash/Check Number: 1„7
ESTIMATED COST(REQUIRED) Date: 11
•Fair market value of all labor and materials foundation to finish • 1—�-A 1.
_
# se, r, Initials: ' _:.._. �G_ ="-"`
G:\PemutCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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