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HomeMy WebLinkAboutBLD2006-00514 L • Review ILDING PERMIT APPLICATIuN M T0500 Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00514 Received Date: 9/7/2006 SITE ADDRESS: 63 N LYTER AVE PORT TOWNSEND, 98368 OWNER: EDWARD THOMAS PHONE: 360-638-2258 KATHLEEN D THOMAS PO BOX 404 HANSVILLE WA 98340 IRONDALE SUBDIVISION: Block: 153 Lot: 12+ PARCEL NUMBER: 962115311 Section: 35 Township: 30 N Range: 01 W CONTRACTOR: HI-LINE HOMES PHONE: 253-840-1849 11306 62ND AVE E PUYALLUP WA 98373 Contractor's License HILINH*981BT Expires 2/10/2008 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr NSFR W/ATT GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION 216,001.00 MAIN: 1,642 CODE EDITION: 2003 ADD'L: 629 HEAT TYPE: HTP OCCUPANCY: R_3 HEAT BASE: HEAT TYPE: EEE OCCUPANCY: UNHEATED: # OF STORIES: CONST TYPE: 5N OTHER: GARAGE: 528 SHORELINE: CONST TYPE: SETBACK: DECK: 256 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 4 Prop: 3 Total: 4 Total: Routing Date: q1-1a Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $1,648.95 LYK 09/07/06 84833 Plan Check $1,071.82 LYK 09/07/06 84833 State Building Code $4.50 LYK 09/07/06 84833 Potable Water Application $55.00 LYK 09/07/06 84833 Total: $2,780.27 0 0 BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00514 Received Date 09/7/2006 SITE ADDRESS: 63 N LYTER AVE Issue Date 10/10/2006 PORT TOWNSEND, 98368 APPLICANT: EDWARD THOMAS PHONE: 360-638-2258 KATHLEEN D THOMAS PO BOX 404 HANSVILLE WA 98340 SUBDIVISION: IRONDALE Block: 153 Lot: 12+ PARCEL NUMBER: 962115311 Section: 35 Township: 30 N Range: 01 W CONTRACTOR: HI-LINE HOMES PHONE: 253-840-1849 11306 62ND AVE E PUYALLUP WA 98373 Contractor's License: HILINH*981E3T Expires: 02/10/2008 PROJECT DESCRIPTION: NSFR WI ATT GARAGE CALL IN FOR THE EQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. SETBACKS: UFFER: //'lo- I Footing: f J '6 —eev Foundation: . ER, e1,16►pe.e-12.S LsrrrEz .DATED 0/22-ict, Stormwater FINAL Approval: (;��E 12,s 1 :5>.ou5abUT< la„peen -tc. PL.45F+BL.:x'KS 5/ cV Underground Plumbing: / Underground Insulation: Shear Wall :: ,4-70 Sheathing: �/O' UN�su�E7C c 4-50 97 Framing: V,pLobi4 (2 -('i-n(#.v f i lc.►:.ar ',CF. 3/12/c,' Plumbin ("�42 "d' 1 Propane ank/ Lines: Insulation: i'i0'A-ci.6 ) Carc,,.vc. i' t:_a.es c". 512.z1o7id Sheetrock: 1\.10 4sEE-;,,7tier fjI Aa16.1tS Septic Sytem Final Approval MUST be obtained before final of structure can be attempted. Road Approach Final Approval: Zoning Final Approval: IaFinal/Occupancy Approval: .QK �. O 7 HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQU ED 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. Office Hours 9:00 a.m. -4:30 p.m. HOT LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY - SEE REVERSE • • SPECIAL CONDITIONS FOR CASE BLD06-005 14 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. 2.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 3.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 4.) 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. 5.) 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. 6.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 7.) 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. 8.) Minimum setback from North Lyter Avenue and North Carnegie Avenue rights-of-ways shall be 20 feet. Minimum side yard 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.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. I:\F_BLD_Permit_Buildng.rpt 10/29/1999 PLAN 227 '1 REVERSE PLAN AVAILABLE ..r Win', ,,,e ry ,.✓!/. „ 1 ✓ 41.;IWr. xM • iw . Jell!' 4 4 / ....... .. ....7nrw.4.7,7 , .p.... . . , /4fro, IIY /M (!/%//� � __ _ / , -. ft. -,-. -=--'111 0 k-------------_,_______,.. , 'f'.-------1A- \----,TrIl ICI ... 7---1 ".' '::___--- ---,d911:- ----.46.‘‘'s-- • -. . _,.. , 0:fr. - -"or- 44-n , la,,-; ,..-1 • ra --1-1-1-1-1-1-1 - rqUI 2 .....-i.-. -0:; mil im, .... imi .7 i j i i i 7_i ra, i_2_11---1=iLlt ill ma .." ••••= 1Fm ill MI -1-1-1-1-1-1-1-1 • ;... - ."44"1 .mow'/iVjr ,�,li _ -.-.� ..ir-.,/,; ..__;:+,_ "`-y''v :% "vim r " L, ;;..iah_ l,rv/.0.+•• 4,� ' p f1sAv... 58' --tip f—EATING BAR 00 DINING RM. 0O BDRM.2 BDRM.3 12 x 12 FAMILY RM. MSTR BDRM 10-9 x 12 5 11-5 x 10-1 KITCHEN 19-1x15-8 13-1x15-10 - .......,6 LIVING RM. PWD b `� BATH • BATH 12 x 14-9 COAT ENTRY - IDEN AIL-, WALK-IN r-{ BDRM.4 L. r ---1 I l o x 9-s F-- C oa r ``''� N 10-3 x 10-7 CLO. I1 nL n F I COVERED PORCH I a L GARAGE RECEIVED, 24x22 r -; SEP072006 I I .___ I . ,IEfifii304 COOtiff0C0 HiL I\E H O M E S Artist'Conceptual Drawings.Builder reserves right to change plans,specifications&prices without notice. PERMIT # BLD viSOISIT 6 - 0 5 14 ", JEFFERSON COUNTY DEPARTMENT OF COMMUNI Y DEVELOPMENT (co 4.. jp.tt,,,..,,,,,: 621 Sheridan Street - Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax I i , *' �'t httpi/www.co.jefferson.wa.us/commdevelopment/ iri `: .-``"' w.`k '`°�t` STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# 00 5C0 PROJECT/APPUCANT NAME: CD co A-rD , T MA S 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. et-EA AND LEVEL a,ITH ExUSTi4//, PE/d/rjirrE7, ift)ST/4L/L D . Mt)0 BEDa--( 6 PTIC. 2 SYSTP 41 ( 56Po I -O0Q, Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. LEYEL 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. [t)cc7DS 4. Describe the existing soils. Indicate soil type on the site map. ioGA-L iLS _ 4DE40A-T& Fo4 I- CbvurY Pit rTeD, ' BEDi2A,,t SEPrIG 15YS7Es1 C.SE Poi -oo22-9) 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. 5, rE 15 LeVEL To Cooarr 2ohia ( LLTE2 avail)) -1 +4-r / M4-S AN EXi5TiN4. aroL&CQ Poruu,u4 ALoy6 S /D ?ftvz Po47) 6. Describe any excess levels of noise generated by the proposed use or activity: A r r RQV E D /Ya/z4t4-L Aktil6 N5n2ocT10J1/4) 2C1.A-Ten goSiS2RMWATER PLAN (1CT - R 2.006 Required 1,,wt �„ !I JEFFERSO C U T stormwater site plan template—rev.10/12003 Re No l� DFPT.OF I Y F. MF.NT, SIGIATLR • • 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. 11/oA/6--. 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.). -V/} }N l siAAG LE Fnn i c.y 171aAtES , A/ L4,7-5' 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. 9. 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 and differentiate proposed facilities from existing facilities. Frnfr4G. GRftainl, cviGCs 514P[ 7v Fx/ ST/4/ CoLu 7' 10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment tacit-dies 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.] th �OAC� 11. Describe the performance goals and standards applicable to the project. ,) STr1-/yDiNl evAt-7 //1 Oft f)2) i4 & rr)c%v1,c-T/o�/ 12. Describe th''firm/rnntml c%,e+e.,, s %c •.-, CJ,1J 5_1)_C il,r !T 5/'L'1,5,1 2 e�. j-it:A- xet-- C G-% -TAU%✓ P infal JEFFERSON pj.5 r,{tl stormwater site plan template-rev.10/1/2003 v���+ q - [ 6 • ! • 13. Describe the water quality system. 14. Describe the conveyance system analysis and design. C'v u N r-4- f,2o. i eTD W PrTeS 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. /1/o4/C Quip(-Th 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. 18. Describe methods for restoration of the site. -')/2 5 70 B Pe 9-tiT6� 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. 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. /Yo,t/L( PERMIT if RED 0 -6 051 JEFFERSON COUNTY BCD 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. Sun xt ' /7rAvri FJED c)I/rJ'C ,4140-/ 4& AuP 5 5 A-,vp .r3 c of PPop6-JT1-• 7?) Re. i --i s n2/,v4 201J sTA- $ 2. Establish Construction Access. EX'Sr N G ,4l7 fi-ff,Qo -c t .44)7. h-�17/T7o N 4-6- 6fZA-1)EL- (A)/ BF /4-7)r7E7 /f E 3. Control Flow Rates. t,t) r-4 5 -t, tt-T 6 24:D E 76 �• U .v6:nr A L-e)ter' 5_1D E Pe-v PC)Al) 4. Install Sediment Controls. LC E._ 5. Stabilize Soils. 1.- vE7-- 1' 6. Protect Slopes. /1/v4/G 7. Protect Drain Inlets. PERM .JL1tLi say CiiW tY UCr stormwater site plan template—rev.10/1/2003 8 • • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. i//" 9. Control Pollutants.02" 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). DVE//s'6-6- U7I ?77z -eg,/IS wt/2k t106 Ol) riE S n /'1D K 3' Aa GLc,4Aiel) uP 12. Manage the Project. PPi2tov/ci?w.c 'vcPEcr OA/ ea vsrgix7'oo it p F 4S" 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). VAC A)T L675 ©N 51,967.5 lit 12 B411 Of Pfi, J. P44)67) C(x4<irY 41) C C,YTL-R (ZolvD) ON Pi Otis 5 1 D C b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). 00weaS,?0 S ry SQL45-Ne4>C/cS TZ' ✓ r €4-z vL66)4PJCI • 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. /1.704/1C-- IF RIM JEFFERSON LUUNTY DCD stoimwater site plan template—rev.10/12003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. 4//111 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). 51,1-E 15 1.CvEL c)i rN ileAv y t!v E1 7> C40f1G-',_ 5. Construction Phasing. a. Construction sequence 4/4>j' / del) lk),44L C0.0 5 rine, r'° b. Construction phasing(if proposed) Allet 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. 5_T-42r I4N91rQuCr/OA) /MIKE A/A-rgLY ifoz *(Eer a,C Boirpi bG P -12111tr 4)72 Coif r Div rov2 /01.0,4,rH$ II. Wet Season Construction Activities. a. Proposed wet season construction activities. A441c.2 "iv tr5E C.v5T2vGric)A) b. Proposed wet season cons ruction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. 6-Dw_412P P. T /045. b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. /r/el b. Diversions. `///,¢- c. Waterways. ,i/ d. Runoff/Stormwater Detention Calculations /i¢ v 4 JEFFERS1. ULM, : UCti stormwater site pan template—rev.10112003 10 • • 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. (LANDOWNER OR AUT ORIZ REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: PERMIT # Bill O 6• O 5 1 4 JEFFERSON COUNTY DCO stormwater site plan template—rev.10/1/2003 12 4 N C • � u\\.1� ,, _J�.,1 `,; , i ,��i b,, JEFFERSON COUNTY Ln c \y am DEPARTMENT OF COMMUNITY DEVELOPMENT � � '' y '�i 621 Sheridan Street• Port Townsend •Washington 98368 Zt1JJ6 360/379-4450. 360/379-4451 Fax www.co.jefferson.wa.us/com mdevelopment irr, t• Master Permit Application MLA: CIO-G Project Description(include separate sheets as necessary): / /Y64) 6/ /6(.0 FAA?, ..; //p,Nc- to,rN /9T7-AC/iE C/WA6E- Tax Parcel 96 a —3 Property Number. I/5 // Size: .3v/js� o,o (acres/square feet) Site Address and/or Directions to Property: (�3 LYTe12 ah-D, '''r T ivia se-AI , WA Property Owner(s)of Record: 6- uJ i2 • C. frl Telephone:360 — b 3 8"27►58 Fax e il: 'b, u it!e e6.vnia-TEL.Ke T Mailing Address: P.U. &x vos1 , /a/A /5(/l LGL, Li 1 f. 98.3 y G Applicant/Agent(if different from owner): ^//A Telephone: Fax: email: Mailing Address: Vyhat kind of Permit?(Check each box that applies) 'Building ['Variance(Minor,Major or Reasonable Economic Use) emolition Permit ❑Conditional Use[C(a),C(d),or C)** Ingle Fa °Discretionary"D"or Unnamed Use Classification Garager Alta Detached °Special Use(Essential Public Facilities)** CI Modular Home °Boundary Line Adjustment 1C Short Plat Q Commercial* (]Binding Site Plan** Q Change of Use d Long Plat** Q Address i Road Approach °Planned Rural Residential Development(PRRD)IAmendments** Propane ❑Plat Vacation/Alteration'* DAllowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑Shoreline Management Substantial Development'"` ❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Variance ❑Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment OWireless Telecommunication* OJefferson County Shoreline Master Program Amendment ❑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 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 attomey'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 entrywill assumed unless the applicant informs the County bepPl in writing at the time of the appli on that he she nts p" notice.Signature: "• 0►j Date: 7 p 4 he. The action 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-transfe le res ibi .,for addherirAr to and complying with the ESA. The Applicant has read this discl r a signs and dates it below. Signature: �jy(p.,, Date: D:\PecmitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc • I 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 assu ing the__ responsibility o jhe G eral Contractor for the proposed project.je / / Signature: rU fG�' f l t1_ -aso ' Date: T/f,4 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: "A. 4/hag /lc'i1E5 (360 c'67-/gs' ( ) MAILING ADDRESS: 12/3 I-0 A,G /2014D EMAIL: CONTRACTORS LICENSE de/n-4.4 4.1 A,W A l8S3/ WAINS NUMBER: ESL INN* 9e/ 8 7- NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Prpject Type: Fie Type: Bathrooms: Shoreline: Type of Sewage Disposal: LW New C$ Wood Existing: 0 Sewer ❑ Addition 0 Steel Proposed: t. Bank ❑Community System ❑ Alteration/Remodel 0 Concrete Total: 27,... lL Height: 110 Individual System ❑ Repair ❑ Masonry ,/i— SEP Permit#Sc'f O1-OO2 2? ❑ Demolition 0 Other Bedrooms: Water Supply: Existing: Setback: 0 irivate well U Two Party Type of Heat: Proposed: SfUrPublic MEAT"Pu MP Total: �f -- Name of System:Pill)D# L uarrtt lydilul¢GC: ❑ OF 3EFFERScw Cots ar: 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: 0 Underground Tank 0 Above ground Tank Size of Propane Tank: 0 Heat Stove 0 Cook Stove 0 Woodstove ❑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 properly 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 �6, Z 14-11/2 412 EH Bld App Review 22 Floor Heated �(,3-f�21 Consistency Review 61? n3cip Other Heated Base fee: I Mezzanine Additional Section: C —' Heated Basement Plan Check fee: a r b`l 2- Unheated Basement StateSurcharge fee: a _ 4.5o Other Unheated G Pot Water Review fee: Garage/Carport 6-28 i24444q# SUBTOTAL DecksFl�pT l�o(2.G f.{ 2.564b33Gz 911/Rd Approach fee: Other TOTAL: $..3E-1 )..3 r] Receipt Number: {(� ( ,�2?� Cash/Check Number. `, 4 ESTIMATED COST(REQUIRED) 21(,col OZ Date: Irl 1� .Fair market value of all labor and materials foundation to finish "t 'h2<l G So Initials: D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc "••••IMIIIIIIIIIIIIIIIIIIIIIIIIIII • L,17,(-1-k e-cif netku- 4Ne/"`Ae-- c\ r) 1--- ‘•)I1 1-r- 0 ra :'-• -c, q-, •C R1 1.\ '11 0- 7) '-‘1 I ; f- .. kl 1 - I f'") i t,.) 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