HomeMy WebLinkAboutCOM2007-00028 Final Change in Tenant-Lil Moes - COM Permit / Conditions - 9/28/2007 MASON COUNTY DEPT. OF COMMUNITY DEVELOPMENT Inspection Line(360)427-7262
Mason County Bldg. 3 426 W. Cedar P.O. Box 186 Phone: (360)427-9670,ext. 352
11 Shelton, WA 98584
010
00MMERCIAL BUILDING PERMIT COM2007-00028
OWNER: CAREN RICH RECEIVED: 4/12/2007
CONTRACTOR: LICENSE: EXP: ISSUED: 5/31/2007
SITE ADDRESS: 24131 NE STATE ROUTE 3 BELFAIR EXPIRES: 11/30/2007
PARCEL NUMBER: 123283290040
LEGAL DESCRIPTION: PCL 6 OF BLA#01-71 (R) PTN NW SW
PROJECT DESCRIPTION: DIRECTIONS TO SITE:
change in tenant- LIL MOE'S
General Information Construction &Occupancy Information
Type of Use: commercial Insp. Area: No. of Units: Type of Constr.: VB
Type of Work: TRA Fire Dist.: 2 No. of Bathrooms: 2 Occ. Group: A2
Valuation: No. of Stories: Occ. Load:
Building Height:
Pre-Manufactured Unit Information Square Footage Information
Make: Length: Lot Size:
Model: Width: Building: 3,277
Year: Serial No.: Basement: Parking Spaces:
Setback Information
Shoreline& Planning Information
Front: Ft. Shoreline: Ft.
Rear: Ft. Slope: Ft. Water Body: Shoreline Desig.: Not Applicable
Side 1: Ft. SEPA?:No Comp.Plan Desig.: Urban Growth Area
Side 2: Ft.
Fire Protection System Information
Auto Fire Alarm System?: Emergency Key Box?: Standpipe?:
Auto Fire Sprinkler System?: Access Road?: Fire Extinguishers?:
Fixed Fire Suppression System?: Fire Hydrants?: Fire Lanes?:
COM2007-00028 Please refer to the following pages for conditions of this permit. 1 of 6
Plumbing Fixtures Mechanical Fixtures FEES
Type Qty. Type Qty. Type By Date Amount Receipt
Change of Use KKK A/19/,2nn7 t19n Fn R1gnn7nn
Building State Fee KKK All?/,2nn7 td Fn R1gnn7nn
EH Plan Review Tvv ai,Annnn7 t7F nn Rtgnn7nn
UFC Plan Check Fee I Aw F11nnnn7 tan nn PH9nn7nn
ADJUST--Change of nl r. Fvt 1 nnn7 to Fn Rl gnn7nn
Total $264.50
CASE NOTES FOR
COM2007-00028
CONDITIONS FOR
COM2007-00028
1) Any expansion of business will need approval of Mason County Public Health.
COM2007-00028 2 of 6
2) A key box (knox box) is required to be installed on the exterior of the building for Fire Dept. access per section 506 of the 2003 International Fire
Code. Contact the Local Fire District for information and inspection.
x 0441
Cooking appliances are required to have a type I hood and duct system located directly over them and a UL 300 compliant fire suppression system
is repired. A separate permit is required for any changes or repairs to the existing systems if found not in compliance at the time of inspection.
X
Install 2A10BC fire extinguishers so that no distance of travel exceeds 75 ft. in any direction. Mounted not more than 60 inches above the floor to
the top of the unit on an approved bracket. k fW, (
Install 1 type K fire extinguisher within 30 ft. of the cooking surfaces but no closer than 10 ft. X CM
\
The building is subject to inspection and corrections as deem ed-Qecessaryby the Mason County Fire Marshal to meet the minimum fire and life
safety requirements as adopted by Mason County. X C� �\A_l
An automatic sprinkler system shall be provided throughout a structure with an occupancy used as a nightclub. Existing nightclubs constructed
prior tp July 1, 2006 shall be provided with automatic sprinklers no later than Dec.1, 2007.
X
Rooms and enclosed spaces are required to have interior wall and ceiling finishes of class C or better with a smoke-developed index of 0-450 and
a flame spead index of 76-450.
Provif all product information at the time of inspection that shows the finish materials are in compliance. X
l N"
3) This project approved without changes to the existing structure that would normally require a building permit. The continued use will be the same,
an assembly area classified as an A-2 occupancy.
X ( " � j'-',
T'
4) EXITS & EXIT ACCESS DOORS
All doors shall be side hinged and swing in the direction of exit travel. All exit doors shall be illuminated at all times that the building is occupied
and be equipped with approved panic hardware,accessible installed in accordance to requirements for persons with disabilities.
ALL exits and exit access doors, and other areas marked on the approved plans, shall be marked by an approved exit sign readily visible from any
direction of egress travel. All exit signs shall be internally or externally illuminated at all times and equipped with to ensure continued illumination
for a duration of at least 90-minutes.
X �
5) All kitchen hood systems shall be installed and maintained as required by the International Fire Code, Building Code and Mechanical Code.
Inspection and maintenance records shall be available for inspectors during all inspections.
X OJYA r_-
COM2007-00028 3 of 6
6) A-2 Occupancy/Sprinkler System
The occupant load of 277 is approved as shown on the approved plans and does not include outside dining area as the area is not enclosed by
walls or a roof.
Section 903.2.1.2 specifies that an automatic sprinkler system will be required where one of the following occurs:
1) The fire area exceeds 500 square feet.
2) The fire area has an occupant load of 100 or more.
3) The fire area is located on a floor other than the level of exit discharge.
Changes to the outside dining area or inside assembly area may affect occupant load and cause the structure to require an automatic sprinkler
system.X o n n
" e_
7) This project is approved and shall be completed prior to the final occupancy inspection, subject to the following requirements:
1)At least one accessible building entrance.
2) At least one accessible route from an accessible building entrance to primary function area.
3)Accessible signage.
4)Accessible parking in accordance to approved standards.
X
8) Contractor registration laws are governed under RCW 18.27 and enforced by the WA State Dept of Labor and Industries, Contractor Compliance
Division. There are potential risks and monetary liabilities to the homeowner for using an unregistered contractor. Further information can be
obtained at 1-800-64r7;09§2. The person signing this condition is either the homeowner, agent for the owner or a registered contractor according to
WA state law. X
9) All approved plans are required to be on-site for inspection purposes. If inspection is called for and plans are not on site, Approval WILL NOT be
granted. In addition, a reinspection fee, based on the current fee schedule, minimum one-hour wiibe Oarged and collected by the Mason County
Building Department prior to any further inspections being performed or approvals granted. X
10) PURSUANT TO INTERNATIONAL CODE, ALL SITES MUST HAVE APPROVED NUMBERS OR ADDRESSES PROVIDED IN SUCH A
POSITION AS TO BE PLAINLY VISIBLE AND LEGIBLE FROM THE STREET OR ROAD FRONTING THE PROPERTY. MASON COUNTY
BUILDING DEPARTMENT REQUIRES THAT THIS BE COMPLETED PRIOR TO CALLING FOR ANY SITE INSPECTIONS. A REINSPECTION
FEE, BASED ON RATES AS ADOPTED BY THE JURISDICTION AND THE INTERNATIONAL CODE WILL BE ASSESSED IF
OWNE&/CONTRACTOR FAILS TO POST ADDRESS ON SITE PRIOR TO REQUESTING INSPECTIONS.
11) Changes to approved building plans that affect compliance to the current Washington State Energy Code (WSEC), ventilation and Indoor Air
Quality Code (VIAQ), Building/Plumbing/Mechanical Codes and/or Mason County Regulations shall be approved prior to construction.
X—I,__ � _
12) CONSTRUCTION PROCESS TO BE FIELD CORRECTED AS REQUIRED PER MASON COUNTY BUILDING DEPARTMENT AND THE
ADOPTED BUILDING CODE.
The construction of the permitted project is subject to inspections by the Mason County Building Department. All construction must be in
conformance with the international codes as amended and adopted by Mason County. Any corrections, changes or alterations required by a
Ma onZqunty Building Inspector shall be made prior to requesting additional inspections.
X 'A
COM2007-00028 4 of 6
13) All building permits shall have a final inspection performed and approved by the Mason County Building Department prior to permit expiration. The
failure to request a final inspection or to obtain approval will be documented in the legal property records on file with Mason County as being
non-comnt with Mason County ordinances and building regulations.
X ���
14) Recyclable materials & Solid Waste Storage: Space shall be provided for the storage of recycled materials and solid waste. The storage area
shall be designed to�et the needs of the occupancy, efficiency of pick-up, and shall be available to occupants and
haulers.) ( )A�L
15) This parcel is located in a smoke management zone. Please contact a fire warden at (360) 427-9670 ext. 459 for further information.
X 0 A_Y�ICI__
This permit becomes null and void if work orconstruction authorized is not commenced within 180 days,or if construction or work is suspended for a period of 180 days at any time after work is
commenced. Evidence of continuation of work is a progress inspection within the 180 day period. Final inspection must be approved before building can be occupied. Proof of continuation of
work is by means of a progress inspection.The owner or the agent on the owners behalf, represents that the information provided is accurate and grants employees of Mason County access to
the above described propert and structure for revie an " speection. 2 1
OWN ER OR AGENT:— DATE: J 1
COM2007-00028 5 of 6
C)
O
CONCRETE MECHANICAL MANUFACTURED HOME C)
C) Date B y ?
Footings!Setbacks Gas piping Ribbons n
o Interior Date By Interior-Date By Date By >
Exterior Date By Exterior-Date By
CO Set-up rn
Point Load I Isolated Footings INSULATION Date By Z
BG I SLAB INSULATION
Date By Data By FIRE DEPARTMENT
Foundation Walls Floors Date By
Date By Data By DECKS
FRAMING Walls Date By
Date By Data By PROPANE TANKS
PLUMBING vault Date By
Date By OTHER
Groundwork Attie .
Data By Date By
Type_
Date By
D.W.v DRYWALL Type: 0
Inc Brace Wan O
Date 8y Date B Date By 9
y FINAL I PECTION c
Water Line Fire Seperatiott p
Date By Date By Date Z By e 4
O
Pass or Request Inspect. c
Type of Insp. Fail Oat DateDone By Comments co
rn
0
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COM
MASON COUNTY V
CHANGE IN TENANT APPLICATION
Complete the Change in Tenant Application and return with a floor plan,site plan,septic pumper's report, septic records and
fee to the Mason County Permit Center, P.O. Box 186, Shelton, WA 98584. Evaluation of the Change in Tenant Application will involve
staff members from the Building, Fire Marshal, Environmental Health, Planning and Public Works offices who will identify compliance
requirements. This application is intended for tenant change only. If construction or remodeling is proposed or required a building
permit will be necessary. Upon approval the permit will be issued to the applicant/tenant. After the permit is issued, schedule an
inspection by calling (360)427-7262. Upon satisfactory inspection a Certificate of Occupancy will be issued and must be posted in a
conspicuous lace on the prernises.
N!11 PROPERTY 1NF0R
Date: 77 Assessor's Parcel Number: I•Z .3 Z S-Z Z .,. 0
Legal Description: 7 E .� Lo rho l l� 3 z r
Building Site Address: •- L`Va` r S Z`.•i'
Method of sewage disposal: Septic O Sewer—name of district:
Water source: O Individual Well O Community Well Public System, name of system: J i„
0'F? tRINVOLVED N;.: H E PROJECT Name of Applicant:
Mailing address: YT _ tA
City: :.r.. State: Zip:
"phone:j-7 S q1 Zo Contact Person: ,*RC Message phone: ,
Proposed business name:
Proposed use: c,,r1 1. ! ,NUM0e� of employees:
Previous business name: S
Describe previous use:
.qP... i��< T 10,114
Check one: )V Detached single level/single tenant O Single level/multi tenant
O Multi level/single tenant O Multi level/multi tenant
Age of structure: Is structure currently If not occupied, how long has it been vacant?
occupied? Yes No Yr. Mo.
Square footage: Basement: First:326C) Mezzanine:, Second:_ 'Third:.
Is the structure heated? Heating type: Circle one:.
Circle one: 'Yes No Ele nct c Liquid Propane Natural Gas Oil
Type of heat: Circle one: Furnace Heat Pump Electric baseboard or wall mount Radian
Will there be any changes to the following? Circle yes or no, if applicable:
Floor lay-out: Yes (o Lighting: Yes (�' Heating: Yes go ,
Exterior Finishes: Yes QN-0 Interior Finishes: Yes ''No Parkin : Yes
Number of restrooms provided: ..') Number of fixtures in each
Is structure handicap accessible? Circle one Yes . No
Is the structure equipped with a fire sprinkler system? Yes No Fire alarm system. Yes No
Monitoring Station Name: Phone number:
�IQT ITT Y
,�.
1. Floor Plan(5 sets):
• Draw the floor plan to scale Use of rooms
• Room Dimensions • Location of all exits and windows (include dimensions)
• Location of plumbing and mechanical fixtures • Interior doors with swing radius
2. Site Plan(5 sets): Note scale used
• Property lines, easements, &right of ways . Location of all existing structures &dimensions
• Distance, in feet,from property line&structures 0 Landscape buffer yards
• On-site sewage tanks and drain fields, & reserve . Well location
• Location of fire hydrants&vehicle access roads • Parking areas number&arrangement)
3. Septic records,pumper's report or O&M report.
4. Fees will be collected at time of submittal
Official;Use Qr�
Accepted by Date Submittal Amount$ Receipt number
Department Review Initials Date Comments
Building
Environmental Health
Fire Marshal
Planning
Public Works
Occupancy Change? (circle one) Yes No Type of construction
Occupancy classification change from to Occupant load calculated: persons
Existing occupant load design persons. Land Use Designation:
Occupancy Classification:
8/23/2007
pConditions Associated With 10:57:11AM
Case#: COM2007-00028
Permit Condition _ Status Updated
item# Code Title Status Changed By Tag Date By
1) 1 ACCESSIBILITY- EXISTING BUILDING NOT MET 5/11/2007 DLC
This project is approved and shall be completed prior to the final occupancy inspection,subject to the
following requirements:
1)At least one accessible building entrance.
2)At least one accessible route from an accessible building entrance to primary function area.
3)Accessible signage. (�
4)Accessible parking in accordance to approved standards. -`\
1
X�o. ��- D ,
2) 1 ANY EXPANSION NOT MET 4/30/2007 TW
Any expansion of business will need approval of Mason County Public Health. 1
x
3) 5030 Changes to Approved Plans NOT MET 5/11/2007 DLC
Changes to approved building plans that affect compliance to the current Washington State Energy Code
(WSEC),ventilation and Indoor Air Quality Code(VIAQ),Building/Plumbing/Mechanical Codes and/or ^�
Mason County Regulations shall be approved prior to construction. l�
X(IXYY`2
4) 1 COMMERCIAL KITCHEN HOOD NOT MET 5/11/2007 DLC
All kitchen hood systems shall be installed and maintained as required by the International Fire Code,Building
Code and Mechanical Code. Inspection and maintenance records shall be available for inspectors during all
inspections.
x
5) 1 EXITS&EXIT ACCESS DOORS NOT MET 5/11/2007 DLC
EXITS&EXIT ACCESS DOORS
All doors shall be side hinged and swing in the direction of exit travel. All exit doors shall be illuminated at all
times that the building is occupied and be equipped with approved panic hardware,accessible installed in
accordance to requirements for persons with disabilities.
ALL exits and exit access doors,and other areas marked on the approved plans, shall be marked by an
approved exit sign readily visible from any direction of egress travel. All exit signs shall be internally or
externally illuminated at all times and equipped with to ensure continued illumination for a duration of at least
90-minutes.
x C`
6) 5045 FIELD CORRECT NOT MET 5/11/2007 DLC
CONSTRUCTION PROCESS TO BE FIELD CORRECTED AS REQUIRED PER MASON COUNTY
BUILDING DEPARTMENT AND THE ADOPTED BUILDING CODE.
The construction of the permitted project is subject to inspections by the Mason County Building Department.
All construction must be in conformance with the international codes as amended and adopted by Mason
County. Any corrections,changes or alterations required by a Mason County Building Inspector shall be made
prior o requesting additional inspections.
Xvti �
Pagel of 3 CaseConditions-rpt
8/23/2007
Conditions Associated With 10:57:11AM
No,, Case#: COM2007-00028
Permit Condition Status Updated
item# Code Title Status Changed By Tag Date By
11) 700 RCW 18.27 NOT MET 5/11/2007 DLC
Contractor registration laws are governed under RCW 18.27 and enforced by the WA State Dept of Labor and
Industries,Contractor Compliance Division.There are potential risks and monetary liabilities to the
homeowner for using an unregistered contractor.Further information can be obtained at 1-800-647-0982.The
person signing this condition is either the homeowner,agent for the owner or a registered contractor according
to WA state law. X�t�
12) 7000 SMOKE MANAGEMENT ZONE NOT MET 5/14/2007 CMH
This parcel is located in a smoke management zone.Please contact a fire warden at(360)427-9670 ext.459 for
further information.
X 'uV1�
DC 13) 5710 SOLID WASTE STORAGE NOT MET 5/11/2007 DLC
Recyclable materials&Solid Waste Storage: Space shall be provided for the storage of recycled materials and
solid waste. The storage area shall be designed to meet the needs of the occupancy,efficiency of pick-up,and
shall be available to occupants and haulers.X 0 t W�
14) 1 SPRINKLER SYSTEM REQUIRED NOT MET 8/17/2007 DLC
A-2 Occupancy/Sprinkler System
The occupant load of 277 is approved as shown on the approved plans and does not include outside dining area
as the area is not enclosed by walls or a roof. Changes to the outside dining area or inside assembly area may
affect occupant load.
The existingstructure meets the definition of a nightclub:
r�
An A-2 occupancy use under the 2006 International Building Code in which the aggregate area of concentrated
use of unfixed chairs and standing space that is specifically designated and primarily used for dancing or
viewing performers exceeds 350 sq.ft,excluding adjacent lobby areas.
An automatic sprinkler system shall be provided throughout every nightclub. Existing nisghtclubs constructed
prior to July 1,2006 shall be provided with automatic sprinklers not later than December 1,2009.
15) 1 TENANT REVIEW-NO CHANGE NOT MET 5/11/2007 DLC
This project approved without changes to the existing structure that would normally require a building permit.
The continued use will be the same,an assembly area classified as an A-2 occupancy.
x C A�\2
16) 1 FIRE SUPPRESSION SYSTEM NOT MET 8/17/2007 DLC
An automatic fire extinguishing system shall be required for commercial cooking systems and shall be a type
recognized for protection of commercial cooking equipment and exhaust systems.
A separate permit shall be required for the required hood suppression system and fire sprinkler system.
x (' ZN2
Page 3 of 3 CaseConditions-rpt
8/23/2007
Conditions Associated With 10:57:11AM
11 Pro Case#: COM2007-00028
Permit Condition Status Updated
item# Code "Title Status Changed By Tag Date By
7) 5600 FINAL INSPECTION REQUIRED NOT MLT 5/11/2007 DLC
All building permits shall have a final inspection performed and approved by the Mason County Building
Department prior to permit expiration.The failure to request a final inspection or to obtain approval will be
documented in the legal property records on file with Mason County as being non-compliant with Mason
County ordinances and building regulations.
X("-�
8) 270 Fire Marshal Comments NOT MET 5/10/2007 LAW 8/17/2007 DLC
A key box(knox box)is required to be installed on the exterior of the building for Fire Dept.access per section
506 of the 2003 International Fire Code.Contact the Local Fire District for information and inspection.
X r-ti k;?
Cooking appliances are required to have a type I hood and duct system located directly over them and a UL 300
compliant fire suppression system is required.A separate permit is required for any changes or repairs to the
existing systems if found not in compliance at the time of inspection.
X Lwi 2
Install 2A 10BC fire extinguishers so that no distance of travel exceeds 75 ft.in any direction.Mounted not
more than 60 inches above the floor to the top of the unit on an approved bracket.X
CA'N lL
Install 1 e K fire extinguisher within 30 ft. of the cooking surfaces but no closer than 10 ft.X
The building is subject to inspection and corrections as deemed necessary by the Mason County Fire Marshal to
meet the minimum fire and life safety requirements as adopted by Mason County.X
An automatic sprinkler system shall be provided throughout a structure with an occupancy used as a nightclub.
Existing nightclubs constructed prior to July 1,2006 shall be provided with automatic sprinklers no later than
Dec.1,2009.
X1o�b�
Rooms and enclosed spaces are required to have interior wall and ceiling finishes of class C or better with a
smoke-developed index of 0-450 and a flame spead index of 76-450.
Provide all product information at the time of inspection that shows the finish materials are in compliance.X
C-1ib�
9) 1001 PLANS REQUIRED ON SITE NOT MET 5/11/2007 DLC
All approved plans are required to be on-site for inspection purposes. If inspection is called for and plans are
not on site,Approval WILL NOT be granted. In addition,a reinspection fee,based on the current fee schedule,
minimum one-hour will be charged and collected by the Mason County Buil a argent prior to any
further inspections being performed or approvals granted.X11'�c.—
10) 1002 POST ADDRESS NOT MET 5/11/2007 DLC
PURSUANT TO INTERNATIONAL CODE, ALL SITES MUST HAVE APPROVED NUMBERS OR
ADDRESSES PROVIDED IN SUCH A POSITION AS TO BE PLAINLY VISIBLE AND LEGIBLE FROM
THE STREET OR ROAD FRONTING THE PROPERTY.MASON COUNTY BUILDING DEPARTMENT
REQUIRES THAT THIS BE COMPLETED PRIOR TO CALLING FOR ANY SITE INSPECTIONS. A
REINSPECTION FEE, BASED ON RATES AS ADOPTED BY THE JURISDICTION AND THE
INTERNATIONAL CODE WILL BE ASSESSED IF OWNCON��ST ADDRESS
ON SITE PRIOR TO REQUESTING INSPECTIONS.X
Page 2 of 3 CaseConditions..rpt
Request To Revise An Approved Plan
Permit Number: �m - (,b0 Name L I L , IV6C S
Parcel Number 1,9�; - U -gWL0 Phone Number daytime ( 6 0 ) Z 75—W ZO
Project Address 2 9131 ru F 14t,.,t. 3 Mailing Address )Y 131 V E H-w g
Please provide a complete, detailed description of the proposed revisions to the approved plans:
Are two sets of the revised plans or addendum indicating the changes included? XYes ❑ No
Are the approved site plans included? ❑ Yes ❑ No
Are the revisions clearly and accurately identified on the plans or addendum? Or Yes ❑ No
Does the plan contain an engineer's or architect's lateral or vertical analysis? ❑ Yes TESf,No
If Yes, Has the engineer or architect approved this revision? ❑ Yes WNo
Is a stamped and signed approval included with this request? ❑ Yes a'No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? X Yes ❑ No
If Yes, is a revised site plan,with all new setback dimensions included with this request?
• 0 Yes ❑ No
Additional Information: GAW /7 1 a I a
_JR-1111 �44oy i-o" -
W -1 if I OF
Applicant's signature C -� Date: 7//YI6 1
Office Use Only Received by:
Date Sent Assigned To Approved By Date
Original Valuation: $
❑ B. Additional Valuation: $
❑ P. Sq.Ft. x$ $
Sq.Ft. x$ $
❑ E.H. Total New Valuation $
Additional Fees:
❑ P. I� I Additional Planning Dept. $
Additional Plan Review $
New Setbacks: Front ! Rear / Additional Building Permit $
Sidel / Side2 ! Additional Plumbing �53
Additional Conditions/Comments: Additional MechanicalAdditional E.H.Dept. $
Other $
Total Amount Due: $ f 706
- Amount To Be Paid Up-Front$
Tech irvW
' r
Request To Revise An A o`e-�n
9 ppr
Permit Number: BLD200--�_- Name 4 KP l �
Parcel Number - - Phone Number daytime ( )
Project Address Mailing Address
Please provide a complete, detailed description of the proposed revisions to the approved plans:
Are two sets of the revised plans or addendum indicating the changes included? ❑ Yes ❑ No
Are the approved site plans included? . -11A1144 ❑ Yes ❑ No
Are the revisions clearly and accurately identified on tholans or adden um? ❑ Yes ❑ No
Does the plan contain an engineer's or architect's lateral � rl. aj A*sis? ❑ Yes ❑ No
If Yes,Has the engineer or architect approved this`r�e��s 9,. _ �
g PP �, `i,';J ❑ Yes ❑ No
Is a stamped and signed approval included with th;8tr mfl`? ❑ Yes ❑ No
(Note:No structural changes to a"designed"plan will be approved without the written consent of the engineer and/or architect of record.)
Does the proposed revision modify the footprint or location of the structure? ❑ Yes ❑ No
If Yes, Is a revised site plan, with all new setback dimensions included with this request?
❑ Yes ❑ No
Additional Information:
Applicant's signature Date:
Office Use Only Received by:
Date Sent Assigned To Approved By Date
Original Valuation: $
❑ B. Additional Valuation: $
Sq.Ft. x$ $
❑ P. Sq.Ft. x$ $
O E.H. Total New Valuation $
Additional Fees:
❑ P•W• Additional Planning Dept. $
Additional Plan Review $
New Setbacks: Front / Rear / Additional Building Permit $
Sidel / Side2 / Additional Plumbing $
Additional Conditions/Comments: Additional Mechanical $
Additional E.H.Dept. $
Other $
Total Amount Due: $
Amount To Be Paid Up-Front$
Tech initial