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HomeMy WebLinkAboutBLD2001-00526 x U BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD01-00526 Received Date 09/17/2001 SITE ADDRESS: 161 CENTER RD Issue Date 10/31/2001 CHIMACUM, 98325 Expiration Date 10/31/2002 APPLICANT: ERIK VAN BEUZEKOM PHONE: 360-732-7130 PATTIE MILES 161 CENTER RD CHIMACUM WA 98339 SUBDIVISION: Block: Lot: T 20 PARCEL NUMBER: 901142014 Section: 14 Township: 29 N Range: 01 W CONTRACTOR: OWNER PHONE: LOAN LENDER/ BOND HOLDER: PROJECT DESCRIPTION ADDITION AND REMODEL REQUIRED INSPECTIONS: [ ] 6etbacks (Shoreline Setbacks): [ ] Footings: Oft 10-11-ik f t [ ] Foundation: (V. / "4x G' ° [ i Underground Pluming/ der round Insulatio • t'L/%.,., 4-./ //44/,4,1_, -7 5 ,-v✓.i/o; [ ] Shear Wall: FRha/iNc Di< Con l ran ?[ ] Framing/Plumbing: A4. ev LoPe w,�tc oK2,- iS-we— / Aksnd4e,.( oA)-(-2,26-0�. [ i Propane Tank/Lines: [ ] Insulation: Zi¢Sehzn�?`ok (/fi¢.��rP� ..I,,)/) 3—S=01_ / C-7/7,��oa [ ] Sheetrock: ?)ks2 w akk , 3--1-2_--0 z. [ ] Final/Occupancy Approval: HEALTH DEPARTMENT APPROVAL REQUIRED PRIOR TO FINAL INSPECTION. THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. I-le/W-1V* 014- lb-/0-di Office Hours 9:00 a.m. -4:30 p.m. ,IL-e)w)C3/A; SPECIAL CONDITIONS APPLY -SEE REVERSE OCL ��S �� HOT LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS FOR CASE BLD01-00526 1.) The application was reviewed by the Jefferson County Department of Community Development staff on October 4, 2001 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: SUSC aquifer recharge area. 2.) 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. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer 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 (see attached). 5.) 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. 6.) 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). 7.) This approval is for an addition 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. 8.) Maximum lot coverage shall not exceed 25%. 9.) Minimum setback from Center valley road is 30 feet. Minimum side and rear setbacks is 5 feet. 10.) The building height shall not exceed 35 feet. 11.) The parcel is designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 12.) Access to the site is from Center Road (a county major collector road, C931507). 13.) The revised site plan dated October 24, 2001 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 October 29, 2001 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 14.) A minimum of two (2) onsite parking spaces are required for single family residences. i:IF_BLD_Permit_Buildng.rpt 10/29/19 SON 2. Y �� Al- ±9.V • \9SAriNG.�° • JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street Port Townsend, WA 98368 Al Scalf, Director REQUEST FOR FIRE CODE OFFICIAL SERVICES PROJECT #: DESCRIPTION: ,D>sE 7v .c27 �Z/ot) L_ C34-1t.j 7-4172 • REQUESTED BY: /'4-.4?--- P EX/.A�.�/ DATE: O7 fN'F (/ f APPROVED BY: DATE: 411114 SERVICES COMPLETED BY: / ,Vei4'e/e DATE: 2B✓vwv CODE OFFICIAL REVIEW HOURS: 2.4 NOTES: JAv.r.occa-n9A/ oG.o9,,/ • REPORT ATTACHED: ES ENO SON (., 'ON , ).4111... ) "*_.',YING JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Monday, July 11, 2011 RE: BLD01-00526 Erik Van Beuzekom Patty Miles 161 Center Road Chimacum, Wa. 98339 Greetings, Here's the punch list of required items necessary to final your residential building permit. (BLD01-00526) The requirements for any other use will be addressed at another time. 1. Egress windows in bedrooms shall be able to open completely with unobstructed access from the outside. 2. All smoke detectors shall be interconnected with battery backup,minimum one detector per bedroom, outside the bedrooms, one each floor. 3. Provide operational exhaust fans each bathroom (50 cfm min), kitchen(100 cfm min), vundry.room (50 cfm min). 4. All stairs, ramps decks, balconies (over 30")to be provided with code compliant handrails (34"-36") and guardrails (36"residential-42"commercial). 5. All electrical boxes required to have cover plates or fixtures. 6. Seal abandoned chimney inlet in basement. Provide for cleanout in chimney. 7. Replace stove pipe for wood stove. Provide shielding for wall and floor and outside combustion air for wood stove. See attached for clearances. 8. Exterior deck(stage) over 30"requires guard rail or raise ground to within 30" of deck surface out 3"out from edge Hope this helps you to finish your project. Sincerely, c --(- -)s. L Frank Benskin Plans Examiner 360 379-4461 f6enskin@co.j efferson.wa.us Fax 360-379-4451 . i East Jefferson Fire&Rescue Inspection Report Occupancy Address: /lv/ G 7Pr2 40,44, Insp. No.:2011 - Occupancy Name: PR.'ZA-DISE 7zIII ,720 Sc--//-190 IFC Types B,E,F,MOS Mailing Address: spyyF No. Stories: 3 Occupancy[1]: /jf oit Phone& Fax#: Occupancy[2]: 7141/17.6 Emergency Contact[s]: Occupancy[3]:714 rg' Owner/Agent: Inspec. Zone: dWt 1 Business License No.: AiAt Lock Box: Sq. Ft. Est.: INSPECTOR INITIALS ITEM LOCATION/NOTES FOR CORRECTIONS 1. EXITS/AISLES/LIGHTING 1st 2d 3d a.Exit door/aisle obstructed b.Exit door locked c.Exit sign/Em.Ltng.not illuminated-needs repair ✓d.Exit sign not provided T* . let.Aisle width[s] /2's' 4f.ET CEN,06N6415 2. FIRE EXTINGUISHERS a.Extinguisher not provided/inadequate b.Extinguisher needs annual service/tag C.Extinguisher not mounted 3. ELECTRICAL a.Improper use of extension cords b.Improper wiring or appliance c.Less than 30-inch clearance to panel d.Electrical breakers not labeled /e.Cover plates missing/broken .S F. 4 a /7 EN /51 4mo 4. HOUSEKEEPING a.Storage in exitways or mechanical rm. b.Dumpster>5 feet from bldg.or eaves c.Storage>18 inches from sprinkler hds d.St.>24 inches from ceiling(no sprinklers) e.Compressed gas cylinders not secured f. Flammable/Comb.liquid storage 0.Combustible Stor./unprotected basement 5. FIRE ALARM&EXTINGUISHING SYSTEMS a.Fire alarm system needs service b.Sprinkler system needs service Vic.Hood and Exhaust duct needs service 5.f••¢• 5'7Dl/G' #4,0.0 d.Detectors/Sprinklers 6. OTHER a.Openings in rated walls,ceiling b.Fire Lanes not marked or not enforced c.Fire hydrants or FDC obstructed d.Business/Building address not visible e.Smoking Designation VI. Occupancy Load ISG.D. F+or¢ Viler4rTAZ, OE GKS ADDITIONAL ITEMS!COMMENTS!PERMITS REQUIRED Gvac at, 5 V✓s 'EX /•i r /''1.E G/1. CODE sec. 3og j.1A4 C. ED1 2. .164.4,OO/deO c .y vter /W407 cZo a e(, e. c li8o/• GAfi"f•e.E. ' Gd ERrvo ter' o6.e 1..'s.C. f 80/. 4F. 3 -4. Atii /vs.-77-64,,,1 i4rVCE vie of fr,¢Jo- - cAeMi.vEr 'Pee/-1.x.¢80/./9 Gofreurf't nod.44e, a.0,0oo J7as& PAC //t.R eabe ¢0z.2 NO PROBLEMS NOTED!ALL NOTED CORRECTIONS COMPLETED[Inspector's Init.] INITIAL INSPECTION Fire Dept.Member Tali ss.fs Z. ✓ vosvCompany: Date: 6'9'// Owner/Rep.signature Date: REINSPECTIONS 1st [30 days] 2d [10 days] 3d [5 days] Scheduled date[on or after date written]: Date reinspection performed: Inspector initials/company: Owner/agent initials: GENERAL REGULATIONS REDUCED CLEARANCE a (MEASURED TO WALL) CLEARANCE REDUCTION s=; ASSEMBLY , REDUCED �� (MEASURED TO WALL) \ 1. CLEARANCE ' ® 0 1,,,,---,,',... • 7 --Ii . . „.. ,, .,, ,.., ,, , .„ „AIRSPACE AROUND ,1, PERIMETER AND BEHIND THE CLEARANCE REDUCTION SYSTEM REQUIRED CLEARANCE ,;.. WITHOUT PROTECTION . MEASURED TO UNPROTECTED FLOOR PROTECTION s(2: S' For SI: 1 inch=25.4 mm. SIDE WALL `I:,, FIGURE 308.6(1) REDUCED CLEARANCE TO COMBUSTIBLES COMBUSTIBLE WALL NONCOMBUSTIBLE SPACER ,; I. A V �� , REDUCED CLEARANCE ` �7, �1 METHOD�F t` 1, APPLIANCE PROTECTION 9 JL , REQUIRED CLEARANCE t , WITHOUT PROTECTION i<' Y APPLIANCE 4 vcTf/ ON 1D 65 rt E� pieod/,D 4 /8 77! ea/Verdi'/.iset- PLAN VIEW .4' Figure 308.6(2) CLEARANCE TO COMBUSTIBLES 09 INTERNATIONAL MECHANICAL CODE®COMMENTARY 3-37 •. ���SON cbU JEFFERSON COUNTY EP 4RTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street I Port Townsend,WA 98368 I Web:www.co.jefferson.wa.us/communitydevelopment yc;co� Tel:360.379.4450 Fax:360.379.4451 I Email:dcd@co.jefferson.wa.us Building Permits& Inspections I Development Consistency Review(Long Range Planning I Watershed Stewardship Resource Center July 17, 2013 ERIK AND PATRICIA VAN BEUZEKOM 161 CENTER RD CHIMACUM WA, 98325-8701 RE: Building Permit No. BLD01-00526 Dear ERIK AND PATRICIA VAN BEUZEKOM, It has come to our attention that your building permit No. BLD01-00526 has been expired since 10/31/2001. As you may know, our department offers renewal of building permits for an annual fee of: $228. These annual fees owed accumulate each year. Since your permit has been expired since 10/31/2001, your total renewal fees owed are: $435. However, to encourage you to renew your permit and continue with required inspections of your building, our Department is offering to renew your permit for the single-year amount of$228. Once your permit is renewed, you are again eligible to receive County inspections with the goal of completing the building review process over a one-year time period. Having your building receive and pass all of its required inspections is valuable to you as it is your assurance that your building meets adopted standards for quality and safety. Additionally, having documentation that your building has passed required inspections may be required from lenders or buyers if you ever decide to sell or re-finance your building. The reverse side of this letter lists the typical items required for a final inspection approval. To take advantage of this offer, we must receive your full payment of$228 by March 30, 2013. Please make your check or money order payable to: Jefferson County DCD and include your building permit number on your check. You may also pay at our office with check, money order, cash, or credit card. http://www.co.jefferson.wa.us/commdevelopment/Credit%20Card.htm This is the only notice you will receive. If we do not receive your full payment by the due date, your permit will be cancelled. Once cancelled, if you later decide to renew your permit, you will have to apply for an entirely new building permit, pay all associated fees, and comply with current building and zoning code requirements. In the event that your building permit is cancelled and your construction is not finalized by the building inspectors, the County may choose to record a "Notice to Title" on the property, to document the property is out of compliance with the County's development codes. If you have any questions about this offer, you may call our office at: (360) 379-4450 and ask for Permit Technician Lisa Keller. I hope you will take advantage of this offer! Sincerely, Carl Smith, Director JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT UNIFIED DEVELOPMENT CODE TYPE I LAND USE PERMIT APPLICANT: ERIK VAN BEUZEKOM PATTIE MILES 161 CENTER RD CHIMACUM WA 98339 DATE ISSUED: October 31, 2001 DATE EXPIRES: October 31, 2002 MLA NUMBER: MLA01-00487 PROJECT PLANNER: M FARFAN PROJECT DESCRIPTION: ADDITION AND REMODEL PROJECT LOCATION: Parcel number 901 142 014 in Section 14, Township 29, Range 01 West, WM located at Center Rd, Chimacum, WA 98325 FINDINGS: 1.) The Administrator finds that this application complies with applicable provisions of the Unified Developmen Code, all other applicable ordinances and regulations, and is consistent with the Jefferson County Comprehensive Plan and Land Use map. 2.) The application was reviewed by the Jefferson County Department of Community Development staff on October 4, 2001 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: SUSC aquifer recharge area. 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.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 5.) 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). 6.) This approval is for an addition 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. 7.) The parcel is designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective Augus 28, 1998. 8.) Access to the site is from Center Road (a county major collector road, C931507). 9.) The revised site plan dated October 24, 2001 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 October 29, 2001 shall be resubmitted for review and approval by Jefferson County Department of Community Development. CONDITIONS: 1.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer 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 (see attached). 2.) 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. 3.) Maximum lot coverage shall not exceed 25%. 4.) Minimum setback from Center valley road is 30 feet. Minimum side and rear setbacks is 5 feet. 5.) The building height shall not exceed 35 feet. 6.) A minimum of two (2) on-site parking spaces are required for single family residences. NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development. Development pursuant to this permit shall be undertaken subject to the applicable development and performance standards of 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: -Set back buildings, utilities and roads as far as possible from surface waters(streams, rivers, lakes, marine waters), or at least 150 feet from the edge of the water -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 at (206)526-6613, or the U.S. Fish and Wildlife Service at(503) 231-6121. APPEALS: Pursuant to RCW 36.70C, the applicant or any aggrieved party may appeal this final decision to Jefferson County Superior Court within twenty-one(21) calendar days of the date of issuance of this land use decision. For more information related to judical appeals see UDC Section 8.5.2. The SEPA Official has issued a Determination of Significance for this project. This Threshold Determination may not be appeled to the Hearing Examiner. For more information related to SEPA appeals see UDC Section 8.10.12. Ak /0/31/0( UDC Administrator 411111 • e g,}ON •°G,z JEFFERSON COUNTY ti ',�n K; DEPARTMENT OF COMMUNITY DEVELOPMENT 0'. 621 Sheridan Street • Port Townsend • Washington 98368 `3hr11•10 360/379-4450 • 800/831-2678 • 360/379-4451 Fax BUILDING PERMIT SUPPLEMENTAL '� 4-C{.� CONTACT INFORMATION IS-, N. 42) • 4 , .4., Property Owner: ` Ph1 e: C. (if different from applicant) �� Mailing Address: General Contractor: Or Manufactured Home Installer: Phone: Mailing Address: Contractor's State License Number: Expiration Date: Septic Designer: P one: '.'w(2-4- lk � °43$s-- s9 c Mailing Address: fArchi). a Qipx, 12-2 I pod--- I- fuck. u/9- Architect/Engineer: itect:/Engineer: Phone: Mailing Address: Loan Lender/General Phone: Contractor's Bond Holder: A.04.r",ie1 hive_ 07tA,L. 1 -eiso 0 Ci-,q - 3iti Mailing Address: ppill l yra E Jsi4 — ifritet scw e BLD SUPP CNTCT FORM1.doc 3/27/01 Ifl ' BUILL7NG PERMIT APPLICATION Review Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 ' PERMIT #: BLD01-00526 Received Date: 9/17/2001 SITE ADDRESS: 161 CENTER RD CHIMACUM, 98325 OWNER: ERIK VAN BEUZEKOM PHONE: 360-732-7130 PATTIE MILES 161 CENTER RD CHIMACUM WA 98339 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901142014 Section: 14 Township: 29 N Range: 01 W CONTRACTOR: OWNER PHONE: REPRESENTATIVE(S): PROJECT DESCRIPTIO ADDITION AND REMODEL TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP ADD MAIN: 160 VALUATION 42,878.00 ADD'L: 160 HEAT TYPE: RAD CODE EDITION: 1997 HEAT BASE: 160 HEAT TYPE: WOD OCCUPANCY: R-3 UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: 2 Exist: 1 Wetland Erosion Prop: Prop: 2 Seismic Streams Total: 2 Total: 3 Flood Way Floodplain F&W Landslide Routing Date: (a _ 1 Q I \ c Shoreline Aquifer 11 Forest: Commercial Rural Pf0)(Allity Plat Condition& Type Amount Paid By: Date: Receipt: Approved/Date Permit $573.05 ZAN 09/18/01 30379 -- Plan Check $171.92 ZAN 09/18/01 30379 APPROVED . State Building Code $4.50 ZAN 09/18/01 30379 Potable Water Application $30.00 ZAN 09/18/01 30379 OCT 2 9 2001 Total: $779.47 • • .u1 ' DEPT.OF t ' UN , D:i ENT - SIGNA ''1 . �.�:igpli , s elk ON co • '��F`��' {VE'ID w� �� JEFFERSON COUNTY ti kijo ,.44 DEPARTMENT OF COMMUNITY DEVELOPMENT "SEP 17 Zuni ��' yr-.N 621 Sheridan Street • Port Townsend • Washington 98368 IIN360/379-4450 • 800/831-2678 • 360/379-4451 Fax JEFFERSON COUNTY DCD BUILDING PERMIT APPLICATION Project Description: �j-D eA/4. - gevvic k1.1— R,a' vo on . di•i(' Building Type: Project Type: Frame Type: X Single Family New X Wood Garage Attached/Detached Addition / ,Steel Modular X Alteration/Remodel Concrete Commercial Repair Masonry _I Multi-family/#of Units X Demolition : Other: -_ Industrial Other: Bedrooms: Bathrooms: Type of Sewage Disposal: Type of Heat: Choose one: Existing: Z Existing: _- __ Sewer i Community System Electricity 7.. Oil Proposed: 0 Proposed: 42 XIndividual System Woodstove Propane Total: Z Total: If not sewer,fill out the following: il Heat Pump • • X Conventional Alternative 1g Other (al1iP44*bdk Permit# SEP Water Supply: Private well 1 Two Parry Well Public:. ame of water system: Square Footage: 1 ' For Office Use Only f .0 Main Floor �'I'`[Vo° ' UBC OCCUPANCY GROUP c — r-7 O 2ND Floor // 0 �" c L %J , g4. 1 l�D� I��il hr ,Base fee (0S7• _� 1 J -' II,, 3rd Floor ��� Plan Check fee (q-1.33 I 71 I o I a 2S. `1 ' Htd Basement j "�" [(00 - I4 (:)07)-- State Surcharge fee LI : S V • Unhtd Basement Subtotal Ll ' I - I t V Garage/Carport ,, Pot Water Review fee (.3 O .(.)_C Decks ". it M ft S`t 'V Rd Approach fee ,- -7--- 4- Commercial TO AL 8 i(:.4',"., k-iIndustriale pt# 1c TA9A i Others ' C.sh/Check# / 'YV Total Valu.:o 1. %I` nitials 4-� ,V OCC %/1/ Date 7 ( _2 0/ 1o� (6l Orfrw f =/ 1 4 Estimated Cost: %'a 1 4 If within 200' of the Shoreline, or ' • Distance to Bank or Ordinary High Water 'far' - ik ft.Bank Height ft. By signing the application form,the applicant/owner attests that -c to ormadon provided herein is true and correct to the best of their knowledge. .Any material falsehood or any omission of a material fact made by the applicant/owner with respe t 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 n vht of entry to Jefferson County and it's employees,representatives or agents for the purpose of application review and any required later inspections. Access and right of entry to the c plica is property or structure shall be requested and shall occur during regular business hours. 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