HomeMy WebLinkAboutBLD2013-00336 - WITHDRAWN THIS BUILDING IS
NOT FINALED .
THIS IS AN INCOMPLETE
BUILDING APPLICATION . THE
PERMIT WAS NEVER ISSUED .
IIP w
�,9
ON c ar, JEFFERSON COUNTY
1:1 DEPARTMENT OF COMMUNITY DEVELOPMENT
11 ` ''4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
' � www.co.jefferson.wa.us/commdevelopment
87Ne
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
Gam-- - / sk L - ps, .mI0-,lo .
Tax Parcel Number: ��' v%��� Property Size: r s� (acres/square feet)
Site Address and/or Directions to Property: '
.r1 to -IA i Ire- b t IX-d(6'C% I/1/4
Property Owner(s)of Record: • Cr G( 4�.q 6t-r\ ..
Telephone: 3 g :ax: / email: �- C
Mailing Address: _,,,; rat.'.4 — ,
Applicant/Agent(if different from owner):
Telephone: Fax: ema'.
Mailing Address:
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregat,,n
email:
❑Critical Areas Stew. dship Plan
❑ Demolition Permit / ❑Variance(Minor, „ajor or Reasonable Economic Use)
❑ Single Family ®'Garage Attached Detache. ❑ Conditional Us- [C(a), C(d),or C]**
❑ Manufactured Home .❑ Modular ❑ Discretiona D"or Unnamed Use Classification
❑ Commercial* ❑Special U (Essential Public Facilities)**
❑ Change of Use ❑Bound. Line Adjustment
❑ Address ❑Road Approach ❑Shoe flat**
❑Home Business ❑Cottage Industry ❑ B' ding Site Plan**
❑ Propane P ong Plat**
❑Sign ❑ Plannea Rural 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(S*-4•D)* ❑ Shoreline Management Substantial Development**
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Forest Practices Act/Release • ix-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre—Ape ation Conference ❑Tree Vegetation Request
**Requires a Pre-Application Conference
Please identif other local,state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
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 =ter insffecf.ns. Stffs ccess and right of entry`■will be assumed unless the applicant informs the County in writing at the
time of the applica'.n Eh N he or sh=wa r s p r�f not 007/0‘-e,7 /
Signature: Aj /Ili -./ I Date: !J
The action or actions Applicant will undertake as esult 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-transfe .Zt/orfsir ad en to and complying with the ESA. The Applicant has read this disclaimer and sips and dates it below.
Signature: r Date: LC�. ! .a1�
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
w
BUILDER STATEMENT"
The signer of this statement does hereby certi that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
th: : :e y ill assumin he reap• sibilit of th-p-neral Contractor for the proposed project. g
: �.. 4 �i�. Date: % ��!/�1r�
/
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Prgject Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
[t�' (New ❑ Wood Existing: t)-01,t_ 0 Sewer
❑ Addition /Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ 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
lid-
• 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:
i Underground Tank i Above ground Tank Size of Propane Tank:
I Heat Stove I Cook Stove i Woodstove I Fireplace Insert i Hot Water Tank I 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 For Office Use only, Amount
Revision
Main Floor Heated EH Bld App Review:
Floor Heated Consistency Review: 294
C1 _
Other Heated Buse fee:. . .2)
Mezzanine Additional Section: r/
Heated Basement (Plan Check fee: — 'L�j�\�
Unheated Basement State Surcharge fee: �I/��--•
Other Unheated Pot Water Review fee:
Garage/Carport / A O SUBTOTAL r�� J
V sr `�
Decks d �911/Rd Approach fee: . 4 30 4 Other -1 2`?S TOTAL: $ �°� '�
Receipt Number: 1C4S—Ltt-1 y
6 n(V Cash/Check Number: —S 2S( 10 �( r
ESTIMATED COST(REQUIRED - I V Date: I Ip
*Fair market value of all labor and mat s •undation to finish IC /l 41 ( 7
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
w_sON coG JEFFER.I COUNTY 0
ti. DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street I Port Townsend,WA 98368 I Web:www.co.iefferson.wa.usicommunitvdevelopment
lsy °,, Tel:360.379.4450 I Fax:360.379.4451 I Email:dcd(a.co.iefferson.wa.us
Building Permits&Inspections I Development Consistency Review I Long Range Planning I Watershed Stewardship Resource Center
ONLY COMPLETE APPLICATIONS ARE ACCEPTED.
A COMPLETE BUILDING PERMIT APPLICATION CONSISTS OF:
Master Permit Application Form. This form is to be completed for all permits. Each Building permit requires a
separate Master Permit Application form. Consistency review will include checking environmentally sensitive areas,
stormwater, site visits, lot coverage and setbacks, etc. The consistency review has an hourly fee. The total fee is
calculated after the review and any difference must be received prior to issuance of permits.
THE PROPERTY OWNER OF RECORD MUST SIGN THIS FORM.
//THE
Sets of Plans for Residential—Three Sets of Plans for Commercial. (Commercial app wlbev or food
service requires Health dept Plan Review Form. Two sets of plans are required a building permit, one set is
returned as approved construction set. Drawings to be provided with all dimensions &to scale, %4' = 1' preferred. If an
Architect or Engineer(Licensed in the State of WA.) has prepared your plans, one set must have original signature &
wet stamp on each page. At plan submittal all lateral &structural calculations by(Architect or Engineer) such as
strapping, nailing, shearwalls, beam sizes, grade&species of lumber, truss design, holdowns, etc., shall be on plans
and in details. Plans shall include elevations, foundation, floor(structural), roof plans, cross sections &floor plans with
all rooms labeled.
❑ Manufactured Homes require no plans at time of submittal, However, at time of all inspections, the required
Set up manual must be on site with permit or no inspection will be performed. (re-inspect fee will be assessed).
❑ Mobile Home Information Form - record for Assessor office, must have all mobile home information.
V2'Floor plan—We need 3 copies.All rooms must be labeled. Submit on no larger than 11X 17 paper size.
VThe Universal Plot Plan (Site Plan)— We cannot copy site plans larger than 11"x 17". If the page is larger than
11" x 17" please submit 7 copies. Make sure your plot plan shows setbacks where applicable from shoreline, septic
tank, drainfield, between well and drainfield, from other structures, from property boundaries, from roads, etc. Refer to
the Site Plan Checklist on the reverse side of this page to insure all requirements have been addressed.
❑ Water Availability Information -Gather and submit all required information n the well or bllic date th supply,s form as
described in the Determination of Adequate Potable Water Supply application.
�� • -••••∎GS•i•[=�-i• r:1•TiliSTIOCA-'11139
0 'pplied for,or received,an approved On-Site Sewage Disposal Permit. *Please be aware that the system may
need to be brought up to assistance frogmlDeptsoflEnvironmental Health staffss available at hourly further assistance in
"�`\this matter, technical ass
C0 li
x isting septic system is current with required monitoring inspection. If system has a pump, then 0 & M
professional inspection within last 12
Health for months. If of i entional gravity,360-37 n 044. M professional inspection within the last 3
yes. Contact Environmental
rr Site Address (911#)form
. I"Road Approach application is required if you access your property from a Jefferson County Road. Please contact
Jefferson County Public works at 360-385-9160 for application forms and fees.
❑ State Highway Access Connection Approval is required if you access your property from a WA State Highway.
Call Dale Severson at(360) 357-2736.
V(Stormwater Management Calculation Worksheet—All building applications. If the project creates more than 2,000
ft2 of impervious surface or will have
Prevention land-disturbing gn (SWPPP)will ft2 ror more, a Permanent Stormwater Control Plan and
a Construction Stormwater Pollution
❑ Provide Any Studies or Reports for the Subject Property For example—Geotech Report, Wetland Delineation,
FloodCertificate, etc.
❑ Shoreline Exemption Permit—Development within Shoreline Jurisdiction (200 ft of Ordinary High Water Mark.)
No additional form is required for single family residences unless storm water tight line to beach is proposed.
❑ Permit Fees are calculated and payable at the time of application.
OTHER PERMIT APPLICATIONS WILL HAVE OTHER REQUIREMENTS
,t
•
Site Plan Checklist
A Site Plan. All site plans shall be drawn with a straight edge & features shall be to scale using an engineer
scale.
For Residential Applications
A site plan printed on 11 X 17 to scale. Please show the following on all site plans.
❑ North arrow
❑ Title block with the project name, address, drawing title, tax parcel number, & the name/address/phone of
the person preparing the drawing.
All Property boundaries, dimensions, total parcel acreage or square footage dimensions.
❑ Building footprint square footage for all proposed & existing structures [for Site Plan Approval Advance
Determination (SPAAD)applications show buildable area rather than building footprint]
❑ Environmentally sensitive areas such as ravines, seasonal creeks, bodies of water, wetlands, steep slopes,
etc.
On-site septic system location or sewer lines (existing or proposed). Show measurement from foundation
to septic tank, drainfield, & reserve area. Show transport line.
Well locations, water lines &water meters. Show 100' radius around wells.
❑ Impervious surfaces such as driveways or patios. Show driveways all the way to access road, not just to
the property boundary.
Setback distances from:
o property boundaries to structures or use
o distance between structures
o distances from structures to environmentally sensitive areas such as wetland, shorelines, top and
toe of steep banks or slopes, etc.
❑ Location of any easements &encumbrances such as utility or access easements.
❑ Method & location of stormwater disposal facilitates such as drainage swales, tightlines, dry wells, curtain
drains, etc.
• For applications on marine or river shorelines show ordinary high water mark, top of banks & heights of
banks.
• Locate the Propane Tank, Size of tank, A/G or U/G & distance from nearest building.
For Commercial Industrial Multifamil & Small-scale Recreational &Tourist Uses as listed in Table 3-1
A site plan prepared by a licensed civil engineer, architect, or landscape architect containing the following
information in addition to the general information required above (in these instances, site plans may be printed on
larger paper).
❑ All existing & proposed development or use areas.
❑ Existing structures&significant features on the subject property&on adjacent properties.
Property lines, adjoining street, &immediately adjoining properties &their ownership.
❑ The layout of an internal vehicular& pedestrian circulation system, including location & dimensions of
existing & proposed improvements on public right-of—way such as roads, sidewalks, &curbs.
❑ Corner grades& existing contours of topography at five-foot contour intervals.
❑ Existing & proposed grades & volume& disposition of excavated material, if applicable
❑ Natural drainage direction &storm drainage facilities & improvements.
Locations of all existing & proposed utility connections.
❑ On-site septic system location or sewer lines (existing or proposed). Show measurement from
foundation to septic tank, drainfield, & reserve area. Show transport line.
Well locations, water lines &water meters. Show 100' radius around wells.
Parking spaces &driveways.
Proposed landscaping.
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� ,gO c�tr JEFFERSOt UNTY •
W DEPARTMENT OF COMMUNITY DEVELOPMENT
I" ►C 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
,q gyp' www.co.jefferson.wa.us/commdevelopment
filirING
Master Permit Application MLA:
Project Des ription(include separate sheets as necessary):
Tax Parcel Number: 0t(y \ O`-" 610 l Property Size: ,21. Ci - Acres/square feet)
Site Address and/or Directions to Property:
—S___/ t v - Aloe__ P4--. 1-1- c(c,c (,)A-
Property Owner(s)of Record: OA r.V1Ct2,( P_ol.„4n.-- .
Telephone: '3 S S 1--Th£c r. Fax: email:
Mailing Address: 2M I U. 1- 7).,---1-1,-- S• , L - \v - Gt v 3 ®(
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies • of or Road Segregation
Wuilding • Critical Areas Stewardship Plan
Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
Single Family ❑Garage Attached/Detache. ❑ Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .❑ Modular - ❑ Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)**
❑ Change of Use ❑ Boundary Line Adjustment
❑ Address ❑ Road Approach_ ❑Short Plat**
❑ Home Business ❑Cottage Industry ❑ Binding Site Plan**
❑ Propane ❑ Long Plat**
❑Sign ., ❑ Plannea Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑Stormwater Management ❑ Shoreline Master Program Exemption/Permit Revisions**
❑Site Plan Approval Advance Determinatio (SPAAD)* ❑ Shoreline Management Substantial Development**
CI Temporary Use ❑ Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Y-ar Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference ❑Tree Vegetation Request
**Requires a Pre-Appl/cation Conference
Please identify any other local, tate or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
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 aterial falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit beine null and void.
I further agree to save,inde nify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in a way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide -cress and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any require• later inspections taffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the appl'•-- '!,�•at-he she 'nor no ce.e it Q T�'
Signature: i, . ,A i /A / wA Date: C
� r
.,,,
The action or actions Applicant will undertake -,- a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a poten ial"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 e Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferabA 7-ponsib''ty fo ad r g to and complying with the ESA. The Applicant has read this dis aimpr and_signs and dates it below.
Signature: , , 'A / Date: C-r // /
If
G:\PemvtCenter\###FORMS###\DRD FORMS\Current 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:
( ) ( )
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: e • 1 ❑ Sewer
❑ Addition ❑ Steel Proposed: 0 Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: _ Height: 0 Individual System
❑ Repair ❑ Masonry SEP Permit#
Bedrooms �a —
❑ Demolition ❑ Other: ���'- . Setback: Water Supply:
Existing: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
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:
i Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove i Woodstove i Fireplace Insert T 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 For Office Use Only .; Amount . Revision
Main Floor Heated EH Bld App Review:
Za Floor Heated Consistency Review:
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $ CA
Receipt Number:
Cash/Check Number: 3 2 5-1.
ESTIMATED COST(REQUIRED) Date: t
'Fair market value of all labor and materials foundation to finish l Vl /
Initials: i, 3
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
3
Memo
Jefferson County
Department of Community Development
621 Sheridan Street
Port Townsend, Washington 98368
(360) 379-4450
FAX (360) 379-4451
TO [Y\
FROM c�( a,4 R ,e
DATE 10 —Irj
COMMENTS
Cwt lI J i I'YI r i& R a r) Rc.: Y4 �a r S
?*Zf`w'iT Sat, i a = 1'o R6i qa co
CA-9 $ i La-Vi om^ o,i4
. • . ,.� 385- 7365
531 -
iLec
/0/76/6
6,,Avto/i4
1820 JEFFERSON S
PO BOX 571
PORT TOWNSEND, WA 98368
(360) 385-9150
Received From:
**ORIGINAL**
Receipt Number 4346
COMMUNITY DEVELOPMENT Receipt Date 10/18/2013
Clerk TCASH
REFUND CK - M REGAN I ^� "�✓ -
nRcpt Fund/Dept Description Revenue Paid
3406 143-000-010 BUILDING BASE & INSPECTIONS 322 10 0 g 308 .00-
143-000-010 ZONING APPROVAL APPLICATIONS 345 81 40 228 . 00-
143 -000- 010 PLAN CHECK FEES 345 83 0 0 252 .20
143-000-010 SEPA/ENVIRONMENTAL REVIEW 345 89 0 0 78 .00
650-511-000 STATE BUILDING CODE FEES 386 0 0 0 4 .50
Total 870 .70-
Tender: Refund 870 .70-
\
Bank et Anterica 22870
TREASURER OF JEFFERSON COUNTY
PORT TOWN Np WA
10/18/2013
PAY TO THE MIKE REGAN
ORDER OF
�s7o.�o
Eight Hundred Seventy and 70/100***"*"`
DOLL AR$ ?
MEMO � �1
Refund DCD fee
s-; tee: .r.� ,� _ .� �, !
M'0 2 28 ?OiN 1; 1 2 3 3088 2 5,: LOS 300°00, ? 3 3tig
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
REFUND REQUEST/POSTING MEMO
DATE: 10/15/2013
The amount of $874.70 received from Mike Regan
(case#)
•61808901 is to be refunded to: Mike Re•an
**NOTES: 388+76 (BLD+DEM permit fees)-152 (two hours intake)=$312.00 refund for 322.10.00.
as a result of: permit application cancellation prior to entry in TM, less two staff hours.
Date&number of original receipt: 10/9/2013 145444
REVENUE
FUND CODE NO. REVENUE SOURCE NAME AMOUNT
143-000-010 322.10.00 BUILDING PERMIT APPLICATIONS BLD 308(see notes above)
143-000-010 322.40.20 ROAD APPROACH PERMIT APPLICATIONS RAP
143-000-010 322.40.30 UTILITY PERMIT APPLICATIONS
143-000-010 322.40.80 ADDRESS FEES 911
143-000-010 334.04.20.20 CTED GRANTS
143-000-010 341.50.00 SALE OF MAPS&PUBLICATIONS PUBS
143-000-010 341.60.00 DUPLICATING SERVICES COP/OUP
143-000-010 345.81.00 SUBDIVISION APPLICATIONS
143-000-010 345.81.10 CAMPER CLUB APPLICATIONS
143-000-010 345.81.20 SHORELINE SUBSTANTIAL DEV.PERMIT APPS
143-000-010 345.81.30 CURRENT USE TAX ASSESSMENT APPLICATIONS
143-000-010 345.81.40 ZONING APPROVAL APPLICATIONS 228.00
143-000-010 345.81.50 CRITICAL AREA REVIEW CAR
143-000-010 345.81.60 CONVERSION OPTION HARVEST PLAN COHP
143-000-010 345.83.00 PLAN CHECK FEES 252.20
143-000-010 345.83.10 FIRE MARSHALL PLAN REVIEW
143-000-010 345.89.00 ENVIRONMENTAL REVIEW/SEPA 78.00
143-000-010 346.22.30.40 DCD Water Review
143-000-010 359.90.60 SHORELINE VIOLATIONS
143-000-010 359.90.65 BUILDING CODE VIOLATIONS
001-250-000 369.90 MISC TREASURER REV-BAD CHECK FEE
127-000-010 346.22.30.10 HEH523 WATER AVAILABILITY FEES H2O
127-000-010 346.22.30.10 HEH541 LIQUID WASTE FEES SEPTIC
127-000-010 346.22.30.10 HEH545 EES 3R0 Party Inspector Report Filing Fee
127-000-010 346.22.30.10 HEH582 SHORT/LONG PLAT FEES
127-000-010 346.22.30.10 HEH549 SEP Other 0/5
@ift)
180-000-010 322.40.50 RIGHT OF WAY APPLICATIONS
180-000-010 343.20.10 ROAD FUND
626-000-010 239.10 PLNG TRUST ACCT
650-511-000 386.00 STATE BLDG CODE FEES 4.50
659-003-030 367.13 FIRE DIST#3.MITIGATION FEES
685-049-030 300.00.00.2900 SCH DIST#49.MITIGATION FEES
TOTAL REFUND $870.70
Authorized person signature:
Treasurer's check#: Date:
Treasurer's signature:
G:/PermitCenter/DEPOSIT/Refund Form 12-2005.doc
•
JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
REFUND REQUEST/POSTING MEMO
DATE: 10/14/2013
The amount of $1,026.70 received from Mike Regan
for (case#) 961808901 is to be refunded to: Mike Regan
as a result of: permit application cancellation prior to entry into TM
Date&number of original receipt: 10/9/2013 145444
REVENUE
FUND CODE NO. REVENUE SOURCE NAME oU
143-000-010 322.10.00 BUILDING PERMIT APPL 5 B • 388+ 76 (bld+dem)
143-000-010 322.40.20 ROAD APPROACH PERMI � A ONS RAP
143-000-010 322.40.30 UTILITY PERMIT APPL CA •N
143-000-010 322.40.80 ADDRESS FEES 91
143-000-010 334.04.20.20 CTED GRANT
143-000-010 341.50.00 SALE OF PS P BLI •TIONS PUBS
ebb'
143-000-010 341.60.00 DUPLICA SERVI 5 COP/DUP
143-000-010 345.81.00 SUBDIVISIO PP,CATIONS
143-000-010 345.81.10 CAMPER CLUB AP' I, •. sat<f5
143-000-010 345.81.20 SHO• LINE ('ANTIA • V.PER T APPS
143-000-010 345.81.30 CU.RE. :� TAX ASSE`, t PLICATIONS
143-000-010 345.81.40 ZO ,8t._ ''PROVAL A'= ATIO 5 228.00 a
143-000-010 345.81.5 / R C AREA 4E E CAR
143-000-010 345.81.6 CO■ .• r 5" ri• _ Y HARVEST PLAN COHP
143-000-010 345.83.00 P A'4 CH 9' 252.20
143-000-010 345.83.10 •MA AL N REVIEW
143-000-010 345.89.00 N st ONMENTAL REVIEW/SEPA 78.00
143-000-010 346.22.30.40 DCD Water Review
143-000-010 359.90.60 SHORELINE VIOLATIONS
143-000-010 359.90.65 BUILDING CODE VIOLATIONS
001-250-000 369.90 MISC TREASURER REV-BAD CHECK FEE
127-000-010 346.22.30.10 H. 523 WATER AVAILABILITY FEES H2O
127-000-010 346.22.30.10 -'EH541 LIQUID WASTE FEES SEPTIC
127-000-010 346.22.30. a HEH545 EES 3RD Party Inspector Report Filing Fee
127-000-010 346.22.3• 0 HEH582 SHORT/LONG PLAT FEES
127-000-010 346.22. 0.10 HEH549 SEP Other 0/S
180-000-010 322.44.50 RIGHT OF WAY APPLICATIONS
180-000-010 343 0.10 ROAD FUND
626-000-010 2 •.10 PLNG TRUST ACCT
650-511-000 .86.00 STATE BLDG CODE FEES 4.50
659-003-030 367.13 FIRE DIST#3.MITIGATION FEES
685-049-030 300.00.00.2900 SCH DIST#49.MITIGATION FEES
TOTAL REFUND ., $1,026.70
Authorized person signature:
Treasurer's check#: Date: 1u//4/f/t
Treasurer's signature:
G:/PermitCenter/DEPOSIT/Refund Form 12-2005.doc
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