HomeMy WebLinkAboutBLD2008-00062 Jefferson County Building Dillon Permit Num• BLD08-00062
Applicant: EADES
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2006 International Building Codes
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
Setbacksi. '
Erosion Control
Foundation Footing
s / 8 dpe LI FF; ks7Au� Sl4/o8
Footing Drains /c�-
Foundation Stem Wall 5 ( 4j
Underground Plumbing -7_,p4, v • ',e ouJuoupL 0.4. 9,-,I1 ! ?/2y/),
Straps(hold downs)
Ext. Shear Wall Nailing
Rough-in Plumbing
Framing
Blocking
Airseal
Insulation:Walls
Insulation: Floors
Insulation:Ceiling
Int. Shear Wall Nailing
Wallboard Nailing
•
Gas Line: Interior
Gas Line: Exterior
Propane Tank
Heat/Chimney Clearance
Drywell/Alt Drainage SEE CONDITION 1 FOR DRYWELL DESIGN CRITERIA.
Address Posted
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
•
CONDITIONS for Building Permit# :BLD08-00062
1.) 2005 DOE STORMWATER MANUAL DRYWELL DESIGN CRITERIA
ALL INFILTRATION SYSTEMS SHOULD BE AT LEAST 10 FEET FROM ANY
STRUCTURE, PROPERTY LINE, OR SENSITIVE AREA.
FOR SITE WITH SEPTIC SYSTEMS, INFILTRATION SYSTEMS MUST BE
DOWNGRADIENT OF THE DRAINFIELD UNLESS THE SITE TOPOGRAPHY CLEARLY
PROHIBITS SUBSURFACE FLOWS FROM INTERSECTING THE DRAINFIELD.
DRYWELL BOTTOMS MUST BE A MINIMUM OF 1 FOOT ABOVE SEASONAL HIGH
GROUNDWATER LEVEL OR IMPERMEABLE SOIL LAYERS.
EACH DRYWELL MAY SERVE UP TO 1000 SQUARE FEET OF IMPERVIOUS
SURFACE FOR EITHER MEDIUM SANDS OR COURSE SANDS.
TYPICALLY DRYWELLS ARE 48 INCHES IN DIAMETER (MINIMUM)AND HAVE A
DEPTH OF 5 FEET(4 FEET OF GRAVEL AND 1 FOOT OF SUITABLE COVER
MATERIAL).
FILTER FABRIC (GEOTEXTILE) MUST BE PLACED ON TOP OF THE DRAIN ROCK
AND ON TRENCH OR DRYWELL SIDES PRIOR TO BACKFILLING.
SPACING BETWEEN DRYWELLS MUST BE A MINIMUM OF 4 FEET.
2.) 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.
3.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
4.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
5.) 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 autormobile 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 requriements 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.
6.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
7.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
8.) Minimum setback from Pebble Lar d Cottage Lane rights-of-ways shall be set.
Minimum west and south property setbacks shall be 5 feet.
9.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
10.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
11.) The building height is not to exceed 35 feet.
12.) PRIOR TO OCCUPANCY& BUILDING FINAL- FINAL APPROVAL OF SEPTIC
SEP07-00033 IS REQUIRED. MUST COMPLY WITH ALL SEPTIC PERMIT
CONDITIONS, STATE AND LOCAL CODES.
13.) A 30' SETBACK SHALL BE MAINTAINED FROM THE ONSITE SEWAGES SYSTEMS
DISPOSAL COMPONENT AND RESERVE AREA TO ANY DOWNSLOPE FOOTING,
CURTAIN OR INTERCEPTOR DRAIN OR DRAINAGE DITCH.
14.) A MINIMUM OF 5' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND
EDGE OF SEPTIC TANK AND PUMP CHAMBER.
15.) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC
TANK, RESERVE & DRAINFIELD.
16.) 10' SEPARATION REQUIRED BETWEEN A WATER LINE AND ALL PORTIONS OF
THE ONSITE SEWAGE SYSTEM; EFFLUENT TRANSPORT LINE, TANKS,
TREATMENT AND DISPOSAL COMPONENTS.
•
JEFFERS COUNTY 1.`,E(--' '
�'�� \`�`j DEPARTMENT OF COMMUNITY DEVELOPMENT
' t ` 621 Sheridan Street • Port Townsend •Washington 98368 FEB 1 3 2008
360/379-4450 • 360/379-4451 Fax
�S N��p www.co.jefferson.wa.us/commdevelopment
40.,
y 1"r'r r.
„tire t I• r �j'fl
Master Permit Application MLA: LA D—
Project Description(include separate sheets as necessary):
Con3-t-r t,LC S' a rri►1 y hfme L.0'ti 1--h ct,-04--m ..,4 ee ic3.ro- e,
Tax Parcel p�, / \Property �
Number: 1 Ta (p G,, (102, (Lor 12,) Size: C(0 (9 ;// (acre square feet
Site Address and/or Directions to Property: L.,Pf- p si t.J Ff_EDEQlc,( L e1" T Loa c.S/! R(C9f fT n rJ 434' te.4
Property Owner(s)of Record: 37 /YI E.� E Epp ES �P a Kt —' _ �IZ14,4Cr'
Telephone: 3(0O 385 "78((� Fax: 3(oO 3 /q B41S(A email: /too )iJG O4-Yi►�pc{..,AJ�eT-
Mailing Address: f,P,I Lott I.SA AO c� Po' n 7-6ct)c•8 D (Alt- QR3 Co$
Applicant/Agent(if different from owner): 0 p • , Ln.c, .
Telephone: (3t0o) 3$5-5(p 53� Fax: ( o)3-19-$ 15 email: roOEi i t e m u.S•r-
MailingAddress:- ?C) I19R YOr1-Tou-DnS id4 koft 9�3(08 J
What kind of Permit?(Check each box that applies)
43uilding i Variance(Minor, Major or Reasonable Economic Use)
i Demolition P-rmit i Conditional Use[C(a), C(d),or C]**
ieljalEV
Discretionary"D"or Unnamed Use Classification
(Garage ••ttache /Detached 1 Special Use(Essential Public Facilities)**
1 Manufactured Home 1 Boundary Line Adjustment
1 Modular I Short Plat**
1 Commercial* i Binding Site Plan**
i Change of Use i Long Plat**
i Ad s !/' t Road Approach PR I 0 ITTE. 1 Planned Rural Residential Development(PRRD)/Amendments**
ropan 1 Plat Vacation/Alteration**
1 A es"Use Consistency Analysis I Shoreline Master Program Exemption/Permit Revisions**
1 Stormwater Management L— 1 Shoreline Management Substantial Development**
1 Site Plan Approval Advance Determination (SPAAD)* 1 Shoreline Management Variance
1 Temporary Use i Comprehensive Plan/UDC/Land Use District Map Amendment
1 Wireless Telecommunication* I Jefferson County Shoreline Master Program Amendment
1 Forest Practices Act/Release of Six-Year Moratorium
*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 i ' ne-• 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 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 a plication that he or she wants prior notice.
Signature: � Date: 4.e4I (T7
The a 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-tran able responsibility for adhering to and complying with the ESA. The Applicant has read this disc i r and signs and dates it below.
Signature: _ Date: if 0 7
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.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 proje t. D
Signature: 6-atGe/.-4--- _ Date: -eiX/ 19 07
GENERAL CONTR5cITOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
4 - ,1• (U'y'''��q J ( 7( 3S 5 =.53 ) 37-1 8 VS
MAILING ''DRESS: EMAIL:sfi gx.jee, - e ,.„../.2,7„,„6„, Ae_y__,
CONTRACTOR'S LICENSE WAIN
NUMBER: NUMBER
ARCHITECT/ENGINEER: �--�r- PHONE (2 6x) ` 5 (0-I3UFAX:( )
MAILING ADDRESS: (� EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
Nlew Flelilood Existing: ❑ Sewer
O Addition ❑ Steel Proposed: 2 Bank 0 Community System
IJ Alteration/Remodel ❑ Concrete Total: .2 Heig LI—Individual System
❑ Repair ❑ Masonry /f// SEP Permit# (�73 5
O Demolition ❑ Other: Bedrooms: I Water Supply:
Existing: Setback: LI Private well LI Two Party
Type of Heat: ,� Proposed: 3 t"Public
..-q ,�(�� Total: 3 Name of System: C4:)./P1
_1 _ `
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 Anoka Installation permit,mark all items below that apply:
Underground Tank - Above ground Tank ize of Propane Tank:
I Heat Stove I Cook S o Win, ove I Fireplace Insert - Hot Water Tank I Pel et Stove I Other
Is this appliance being installed in a Manu . . :- •.:: -ome? Yes / No
When applying for a permit to install a propane tank you must also submit 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 a 04I 1 51 H Bld App Review:
2`4 Floor Heated j Consistency Review:
Other Heated : , ' f ` i `
t IL.,,, se1ee:
Mezzanine �,- Additional Section:
Heated Basement / FEB 1 3 , Ian Check fee:
Unheated Basement State Surcharge fee: l
1 �, 4
Other Unheated / Pet Water Review fee:
95.00
Garage/Carport SUBTOTAL
24', ,1� Ia t5 ��a. a 5'6a I�1
Decks C)) 13f 0 ,ito(0) 7
9
1 1,51151 f 11/Rd Approach fee:
I
Other TOTAL: $3 1 3 tt, )q
Receipt Number: 6t5
Cash/Check Number: OA
CU
ESTIMATED COST(REQUIRED) aat4. 154 1j4 ate: a 3\Dcz
•Fair market value a/labor and mates -foundation to finish `t l O
75 3O=----> Initials:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc
• •
RECEIVED
ON
rikk C% JEFFERSON COUNTY FEB13 2ooa
$4,1DEPARTMENT OF COMMUNITY DEVELO
PMENT
,1 621 Sheridan Street • Port Townsend • Washington 98368 JCffERS t 1\11i DCD
�,'Ct 360/379-4450 • 360/379-4451 Fax
http://www.cojefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# (3:6- PROJECT/APPLICANT NAME: �,�ems'(_,Pr
Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the
applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a
separate stormwater site plan map.
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map.
(r -a. d,r vet,
�i i %` }-� j ne si kP f L ly rebider c_, of
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
GeO r- Lo_i th cc. -�e.u0 t-r— a , .r-
s - Cl i r
Sc o:t 4 br«sh 4 no--ii Oe -Ve8e. t
- nn
4. Describe the existing soils. Indicate soil type on the site map.
5. Describe the existing site hydrology(i.e., drainage; behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of
each. �y� r-
xx Olt )%/ / Ce. , -i � tj.,, 6,e2,,
PPROVED
6. Describe any excess levels of noise generated by the proposed use or activ y5.W. SITE PLAN
ex wa m 64 S►\c 6 C)c)iccnaLA 0,8 1->c -r a LA-Itin --( (&sz
Stormwar •
APR 2 5 2Q08
Require
JEF • OUN
DEPT.OF C I i ` O'
SIGNATURE:
stormwater site plan template—rev.10/1/2003 5
1.
• •
7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map.
8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads,and sensitive/critical areas
(streams,wetlands,lakes,steep slopes,etc.).
Mi S i 5 a_ rQ,S't c e n aJ d eiJ-Z1 t) pm en-4- c rea.
s dev c or under ConStr ;Finn
LoVk Pn -(o 5auH-17t L F
Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation.of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed(i.e., per BMP T5.30
in the Manual) or, if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan a d differentiate proposed facilities from existing facilities.
�1l dov�n oov��s 4 (�UQ-BnO\& dre ns -e)
en .Qo5e..c4 Y Lon k-c- cam.c x ()Nu
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10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for"large"projects or projects that involve the potential for dispersion of contaminants.]
NOY RECEIVED
FEB 13 2008
11. Describe the performance goals and standards applicable to the project.
.tn elYVP rtffERSON COUNTY DCU
12. Describe the flow control system
Ao wn ?o s - ) A r ,t)/2.1
stortnwater site plan tempi ate'rev.10/1/2)03. 6
• •
13. Describe the water quality system. R.1 A
'nP- ` Y FEB�13IV 2008
14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
Mo ,�\ neCdkd
N . a-"A i-E- ru..- r t Y,1\]-e),30.
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
17. Describe the proposed surfacing material.
- c f r c re e
18. Describe methods for restoration of the site.
0.ma nc) 4 1 0 r1
19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
"large"projects only and only those for which facilities are required to control flow or treat runoff.] If included, list the Manuals
here.
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
R./iL
21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here. ^^^^
stormwater site plan template-rev.10/1/2003 7
• •
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I-CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual (beginning on page
2-15).
12 Required Elements-Construction SWPPP
1. Mark Clearing Limits.
C.ter ►r aLr cLAT\cd CA nstr bra
S �e — 1p r ush
mcorA; up ca_ s
2. Establish Construction Access.
`O\v 0 J -VD h o-0-e_ I t+ ra\n o.s r CID n r u-d-c ors
3. Control Flow Rates.
mQ- C.2
�Q�l o - --rn,P s
4. Install Sediment Controls.
nA,i) - ()Q 3 fei-1.' c� , , E C 4,1 V HI )
5. Stabilize Soils. FEB 13 21106
' \ c )—r t CFfEO N COUNTY BCD
6. Protect Slopes.
- nov (0- r\eLdecrt,
7. Protect Drain Inlets.
storrnwater site plan template—rev.10/1/2003 8
• •
12 Required Elements—Construction SWPPP(continued) yk1 j C E IVE D
8. Stabilize Channels and Outlets.
e FEB 13 2008
9. Control Pollutants. JEf F[R�FAN COUNTY 0 E]
6 m9— mo�t n o,t-e
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
a/
11. Maintain Best Management Practices(BMPs).
LA ,.
12. Manage the Project.
e)rfle pkDf n5 ro , - 'in3pes.,-bt v .vtd
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads).
Ytelo con, -}ru r ii r)
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
YL(
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
stormwater site plan template—rev.10/1/2003 9
• •
b. Description of special requirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure).
%WAR,
5. Construction Phasing.
a. Constructio sequ nce _I
��f.cir ' r v�.•-r)C cx*1 or -4rc Y1e 'C'Q O l t'1-�e r't o r) S1 t _J,
r�d.CC '-i ,n't 5h r g
a exj-
b. Construction phasing proposed)
II4
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
II. Wet Season Construction Activities.
a. Proposed wet season construction activities. FEB 1 3 2U08
YLJ R
b. Proposed wet season construction activities for environmentally sensitiveltF i SoN CDUNTy DCD
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
a.mes �.o-r-ke�
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
PC
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable.
a. Sediment Ponds/Traps.
b. Diversions. YL IC\.
c. Waterways.
d. Runoff/Stormwater Detention Calculations
stormwater site plan template—rev.10/1/2003 10
i S
Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property.
/32—cid
(LAN R OR AUTHORIZED REPRESENTATIVE SIGNA ) (DATE ✓
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
RECEIVED
FEB 132000
LIEFFERS N COUNTY DCD
stormwater site plan template—rev.10/1/2003 12
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