HomeMy WebLinkAboutBLD2011-00215 •
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 #: BLD11-00215
SITE ADDRESS: 43 N WILLISON AVE e t 0
Final Issu Date:Dae: 129/18/2011/29/2011
APPLICANT: BERNT P ERICSEN PHONE: 360-385-3602
MARLENE J ERICSEN
1656 S JACOB MILLER RD
PORT TOWNSEND WA 98368-9077
SUBDIVISION: IRONDALE Block: 114 Lot: 16+
PARCEL NUMBER: 962111414 Section: 34 Township: 30 N Range: 01 W
PROJECT DESCRIPTION: NEW M/H - SER# 34525
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2009
EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON12/29/2011
I:\F_BLD_Occupancy.rpt 10/29/19
1
•
MANUFA•RE D/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00215 Received Date: 8/3/2011
SITE ADDRESS: 43 N WILLISON AVE Issue Date: 9/8/2011
APPLICANT: BERNT P ERICSEN
MARLENE J ERICSEN
1656 S JACOB MILLER RD
PORT SUBDIVISION: IRONDALE NSEND WA 98368-9077
Block: 114 Lot: 16+
PARCEL#: 962111414 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR/ BUY RITE HOMES PHONE: (360) 681-0777
DEALER 259403 HWY 101
SEQUIM WA 98382
381- 780
Contractor's License BUYRIH*0840B(3Expi es 5/20/2012
PROJECT DESCRIPTION: NEW M/H -SER#34525
MAKE: KARSTEN YEAR: 2011 SIZE: 68X27
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 U // �
Blocking&Tie Down I-7_ l
Skirting&Ventilation
tz-z-tl 7,
Gas Line: Exterior
Propane Tank ; 1 Pressure Test
Drywell/Alt Drainage l .{''31t111
Address Posted
FTIn N , 1 z\Li111
FINAL INSPECTION 1'„"2_2,�It
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY-SEE REVERSE
BUILDING•
MLA11-00173
PERMIT APPLICATA" Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00215 Received Date: 8/3/2011
SITE ADDRESS: 43 N WILLISON AVE
OWNER: BERNT P ERICSEN PHONE: 360-385-3602
MARLENE J ERICSEN
1656 S JACOB MILLER RD
PORT TOWNSEND WA 98368-9077 IRONDALE
SUBDIVISION: Block: 114 Lot: 16+
PARCEL NUMBER: 962111414 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR: BUY RITE HOMES PHONE: (360) 681-0777
259403 HWY 101
SEQUIM WA 98382
Contractor's License BUYRIH"0840B Expires 5/20/2012
REPRESENTATIVE: BUY-RITE HOMES PHONE (360) 681-0777
BIRDIE (360) 681-0780
259403 HWY 101
PROJECT DESCRIPTIOP NEW M/H - SER# 34525
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 1,836
CODE EDITION: 2009 ADD'L: HEAT TYPE: EEE
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER:
GARAGE: SHORELINE
CONST TYPE: SETBACK:
DECK: 18
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: 05783
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
-I I
Type Amount Paid Bv: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 08/03/11 127973 APPROVEr
Potable Water Application $62.00 LYK 08/03/11 127973
Total: $275.00
SEP g 2011
Jefferson County Planning
& Building Department
• •
SPECIAL CONDITIONS CASE # BLD11-00215
1.) A Declaration of Restrictive Covenant has been recorded on September 7, 2011 under
AFN 562124 for the purpose of consolidating the lots to meet minimum land area
requirements for on-site septic and to allow zero lot line setbacks. The Covenant is strictly
for building and septic purposes only.
2.) The application was reviewed by the Jefferson County Department of Community
Development staff on August 31, 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 and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property:
SARPA; Coastal SIPZ.
3.) 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.
4.) 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.
5.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
6.) 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.
7.) 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.
8.) 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.
I
9.) The applicant is proposing tote or add 1,836 square feet of imperviou•rface and
1,986 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 August 3, 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 September 7, 2011 shall be
resubmitted for review and approval by Jefferson County Department of Community
Development.
13.) This approval is for a Placement of a New 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 Rural Residential 1:5 under the Jefferson County
Comprehensive Land Use Map effective August 28, 1998.
15.) NOTICE: This permit does n•cuse the proponent from complying with•r 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
The Federal Bald and Golden Eagle Protection Act requires landowners within 660 feet
(1/8th of a mile) of an eagle nest to consult with the US Fish and Wildlife Service. This
Eagle Act prohibits anyone from "taking" bald eagles. This federal law defines the term
"take" and describes the possible legal consequences when a "take" occurs. Among
other actions, "take" includes a disturbance of bald eagles or their habitat. Under federal
law a permit may still be required for activities that impact bald eagles or their habitat.
Contact the US Fish and Wildlife Service (http://www.fws.gov/pacific/eagle/) to learn more
about how this law affects your project.
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.
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 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.
18.) This parcel is within a no shooting area per JCC 8.50.
19.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
20.) The road approach permit(RAP007-00190) must be renewed, inspected and finaled by
the Jefferson County Department of Public Works prior to the final inspection/certificate of
occupancy of this residence. Contact Terry Duff, Department of Public Works at
360-385-9159 for the final road approach inspection.
21.) Maximum lot coverage is not•xceed 25%. Lot coverage is defined as aSnt of
impervious surface which includes roof tops, driveways, concrete, etc.
22.) The building height is not to exceed 35 feet.
23.) Building setbacks from Willison Ave & Prospect Ave rights of way is no less than 20 feet.
Side and rear setbacks are no less than 5 feet.
Aug. 02 .ev-011 06 : 08 PM J n & Nina Skinner 360 2183 PAGE. 1/
k� DEPARTMENT o COMMUNITY Di-VELOPMtMNT
-• 821 Sheridan Street Port Townsend•Washington 88366
360/379-4450. 360/379-4451 Fax
U www.co.Jeferson.wa.us/commdevelopment
NI
Master Permit Application MLA: 1 i - i T-
Proj--e Descript►qn(Includ separate sit is as neces
Tax Parcel ( f / C cry��
P
Number: 7/ ///'/ size:
f Sze. / / v. i, (acres/square feet)
Site Address and/or Qirections to Property: / ') j
' .a l4
Property Owner(s)of Record: i/,i• . r.
Telephone: , G•/\-.6 8 - �66 2. _- F,ax: small:
Mailing Address: / . (- .$, c.:" A e..c /k.F. ... f - .t !`— 'u(,.�,04 4 " '
Appll9�nt/Agent of differ° from wrier): e . ��� t
Telephtir� � ' G'..�i L11 (a �'7 :��
�'.�c. ° r�'G' 1 Fax: •��(�-Srg1 7c G email: brrc/1ra.0 br u�•h �.ti01t.00 .esr
Mailing Addrgsig. L2 S /V--(..� ,4yuc ,./.,U 1 .j•.../1!/,Y, /..t�.a V R,5,fs 2. 1 �'
What kind of Permit?(Check each box thaflappiiea ..
XBuiding ❑Variance(Minor,Major or ilea bt ,tic U�
0 Demolition Permit C]Conditional Use(C(a),C( ,v'r
❑Single Family 0 Garage Attached/Detached ❑Discretionary"Q"or Un etA Manufactured Home Q Modular a Special Use(Essential P I edillies)" '
❑ Commercial* ❑Boundary Line AdJustmr,
0 Change of Use 0 Short Plat"* A U G 3 2011
❑ Address • 0 Road Approach ❑Binding Site Plan""
Q Home Business 0 Cottagelndustry ❑Long Plat"" LI
U Propane 0 Planned Rural Residential Oevl lopm -+*.`l:e--J , : is**
C7 Sign 0 Plat Vacation/AlteratIon°" -
0 Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Progra p Ffidi NT
❑Stormwater Management ❑Shoreline Management Substantial Development"
❑Site Plan Approval Advance Determination(SPAAI7)* ❑Shoreline Management Variance
O Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
In► fireless Telecommunication* 0 Jefferson County Shoreline Neater Program Amendment
❑Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetalon Request
`May require a Pre—Application Conference _„ 4"`Requires a Pre-Appllcefion Conference
Rtearse- dentify�a» other loc I,state or fSederal,, rml for thi prOposa1, If known:
t3 L. ' / �( DESIC�NA f NOFAGEt�}'t
I hereby d si .nate. , Z4./ ('. 'x .-d-' to act as my agent in matters relating to this application for permit(s).
O 1(iGit
WNER SIGNATURE (-7 ..-
Data: 1' ' '''/! _
By signing this application torch,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.
1 further agree to save,Indemnify and hold harmless Jefferson County against all liabilities,Judgments,court costs,reasonable attorneys 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 p ide access nd right of entry to Jefferson County and Its employees,representatives or agents for the sole purpose of application
review an any r 'red later in cilons. Staffs access and right of entry will be assumed unless the applicant Informs the County in writing at the time t ap Von that he'o he wants prior notlpe.
Signal re: M6 '. .,,e.' " l...e bete:
The action or actions Applica t will undertake ds 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"BSA."Jefferson County makes no eaeurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the FSA, Any Individual,group or agency can file a lawsuit on behalf of an endangered
action(s)even If •u are in cprh Ilanoe with the Jefferson Countydevelopmente species regarding your
code.The Applicant acknowledges that he,she or It holds individual
and r}pa.ttnsd r.le re:ponsi‘lily for adhering to/and complying with the ESA, The Applicant has mad this disclaimer and signs and dates It below,
Signature: e. G%71' i. • .A./e--• ','
Date:
C:\nkumcntr nod Settings\carat\Local SettingaVremporary Internet Piles\OLKE6\M utat Permit Application 12-1y-2006.Joc
• BUILDER STATEMENT 111
The signer of thisatement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they witt ass ing the resporisibiiity of the G neral Contractor for the proposed project.
Signature: r'z /.'ii ., 4'�<��)c2_,c, -f��- Date:
GEN L CONTF ,TOR O MANUFACTURED HOME INSTALLER:,- PHONE:3 C-(- "-cin V FAX:
J��e /� = /�sr ; CZ, .;✓it ` :{% /. _i« _ ( 1) �, /-e; (. era/ / -( 7 (
MAILIN ADDRESS:
199 05 XJ " /G} / \,� <;et:,> ) W( EMAIL: hirc1.I (0 .1)CcCi-ir e._ltD<,)&5 .('Ck n
CONTRACTOR'S LICENSE U ,- WAINS
NUMBER: M/L 1� A S-;( '/i NUMBER C�'y/il) `-�C1,?5-6ARCHITECT/ENGINEER: / ,-(J- ja;7 PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
,Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
d New V Wood Existing: 1 Sewer
Addition 1 Steel Proposed: Bank _i Community System
Alteration/Remodel 1 Concrete Total: 7 Height: Individual ,Sy stem
Repair Masonry SEP Permit# '� i'
Bedrooms:
Demolition Other: Water Supply:
Existing: Setback: ` Private well - Two Party
Type of Heat: Proposed: 3 Public
Total 3 me of System:( �:1, I',a, Y
w
If this is a Commercial Proiect 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:
0 Underground Tank °Above ground Tank Size of Propane Tank:
❑Heat Stove 0 Cook Stove ❑ 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: ,
46✓4
2nd Floor Heated Consistency Review: 11 7
Other Heated Base fee:
lN r ,�� - �)/ _
Mezzanine r 1"— v C 1 V E Additional Section: --
Heated Basement Plan Check fee:
_ 1
Unheated Basement 2/ kri State Surcharge fee: `____
Other Unheated Pot Water Review fee:�FFERSON COUN ! % 1
DEPT.OF"I i , . .
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
/IOU.oc /8 f- \,,: C I > ) k -,
Other TOTAL: $ --)(�L 1
Receipt Number: C''t (
Cash/Check Number: 1
-1
ESTIMATED COST(REQUIRED) Date: `•• •=� ff
'Fair market value of all labor and materials foundation to finish J l i
Initials: r -->
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C:\Documents and Settings\carat\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc
JACK WESTERMAN II) Jefter...n C.aSt.arth....re
ASSESSOR Pu Box 1220, Port Towritoe..d.WA 98368
436110 3Ls. lAS
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME:
ADDRESS: /�/!�S L S �'� /�l f2� �l� A/
PHONE NO. _(:o-;�Fy5 -
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 oar office determine wheth 4 f4 i¢{=a y on the
tax rolls in Jefferson County or if it has been mow er area.
UI
l►MOBILE HOME DATA:
(A) MAKE /i/W U IL- (0)MODEL - (C)YEA 2/ / /
(D) LENGTH [n�? (E)WIDTH �JWYSE
// OFF OF COMMUNITY DEVIL P AF T
IG)YOUR PURCHASE PRICE(Do not iadade sales tax) 7/,/lc-�,(O PURCHASE DATE,r/W
20 PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 311
(A)FROM WHOM DID YOU PURCHASE MOBILE /fir/41-
ADDRESS
(B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No
It Yes, Previous address of',mobile. Al/X
If No,What County was Mobile assessed is last year.
3►WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes ( No
(B)IF LOCATED IN MOBILE HOME PARK: ( //�
NAME do ADDRESS OF PARK A'/// Lot/Space#
(C) IF NOT LOCATED IN MOBILE HOME PARK: /
NAME OF LAND OWNER:
LOCATION ADDRESS AO) • /1,d ,76') )k-- ./1 l' '27(,--)c 1oii
REAL PROPERTY PARCEL #/DESCRIPTION
\� /
Signature of applicant
THANK YOU FOR YOUR HELP!
12QQ
QJO COSSELL. Property Technician
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DEPT.OF COMMUNITY DEVELOPMENT
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