HomeMy WebLinkAboutBLD2006-00337 • 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 responsibilit of the General Contractor for the proposed project.
Signature: �/Date: cl✓'�✓ ` (�-
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:
0 New 4' Wood Existing: ii/�' ❑ Sewer
❑ Addition ❑ Steel Proposed: '3 Bank Height: ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Individual System
❑ Repair ❑ Masonry "A- iiSEP Permit# UCz' /(3
❑ Demolition ❑ Other: Bedrooms: Wajer Supply:
Existing: f'/r Setback: Private well ❑ Two Party
Type of Heat: Proposed: - ❑ Public
CLE-.T/3/G Total: ?a 1� Name of System:
If this is a Commercial Project you must answer the following: N�.-
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:
❑ Underground Tank kd' Above ground Tank Size of Propane Tank: (20 Gfi I-
❑ Heat Stove ig Cook Stove ❑ Woodstove I I Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove t I Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / ..
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 107(0,31 FN Rld App Review:
2 Floor Heated r ^^^g ctency Review:
Other Heated � F "^-e fee:
Mezzanine ,0'- -Additional Section: —_
Heated Basement /� Plan Check fee: (-3^� P 2
•
Unheated Basement - State Surcharge fee: �( `
Other Unheated Pot Water Review fee:
GC.r;
Garage/Carport • SUBTOTAL
70e5 IWeg7:S?e 3(4020.07
Decks 1911/Rd Approach fee:
c 9 7 I(r`f 2$29 �.,(154-E n c
Other TOTAL: $ 3tog) 5
Receipt Number: S .1
Cash/Check Number: ` (v- I /''i fb�
ESTIMATED COST(REQUIRED) Z.34;7(08,7ts Da : tJ
.Fair market value of all labor and materials ndation_tafinis� ,!-'— „ (l(4 C10
-fii ii-b CO/ .
50 Initials:
G:\PermaCenter\FORMS\ORD FORMS\Master Perm rApplicatiorrt'2-30=053oc