HomeMy WebLinkAboutBLD2022-01033 ADV2022-00134 SFR, 2 Garages - BLD Application - 8/8/2022 MASON COUNTY COMMUNITY SERVICES Permit No
PERMIT ASSISTANCE CENTER:
•BUILDING•PLANNING•PUBLIC HEALTH•FIRE MARSHAL
615 W.Alder Street,Shelton,WA 98584 RECEIVED
Phone Shelton:(360)427-9670 ext.352•Fax:(360)427-7798 Phone
Belfair.(360)275-4467•Phone Elma:(360)482-5269
BUILDING PERMIT APPLICATION AUG Q 8 2022
PROPERTY OWNER INFORMATION: CONTRACTOR INFORMAITZ5 W. Alder
treet
NTAME:Earl Lincoln NAME:Earl Lincoln construction IncNy
MAILING ADDRESS:P.O.Box 368 MAILING ADDRESS:P.O.Box 368
CITY:Belfair STATE:WA ZIP:985285 CITY:Belfair STATE:WA ZTP:98528 �i
PHONE#1:360-801-1540 PHONE:360-801-1540 CELL: 360-649-5386 � (il�
PHONE#2:360.649-5386 Chris Lincoln Son EMAIL:eadlincoinconstructioninc@yahoo.Com `/
EMAIL:earfiincolnconstruclioninc@yahoo.com L&T REG#ccearlllc910gt $Xp, 12/19/23
PRIMARY CONTACT: OWNER E] CONTRACTOR❑ OTHER❑
NAME EefiUnmin EMAIL eadlincwlneonstructioninc@yahoo.com
MAILING ADDRESS P.O.Box 368 CITY Belfair STATE WA ZIP98528
PHONE 360-e01-1540 CELL V.0-6+9-53e6cn�. ur<°insw
PARCEL INFORMATION:
PARCEL NUMBER(12 Digit Number) 1233250-90851 ZONINGR4
LEGAL DESCRIPTION(Abbrcviated) FIRE-DISTRTCT Mason 2
SITE ADDRESS321 NE Alder Creek Ln CITY Belfair
DIRECTIONS TO SITE ADDRESS take hwy 3 to Alder creek lane,go up road to top of hill First lot on right at top
IS THE PROJECT WITHIN 300 FT OF SLOPE(S)GREATER THAN 1 J%: 1'ES8 NO❑ SNOV1'LOAD:25 psf
IS PROPERTY WITHIN 200 FT OF THE FOLLOWING: (Check allr4arnpplr•1:
SALTWATER❑ LAKE❑ RIVER%CREEK❑ POND❑ WETLAND❑ SEASONAL RUNOFF❑ STREAM❑
3 TYPE OF WORK: NEW E] ADDITION❑ 4LTERATION❑ REPAIR❑ OTHER ❑
- USE OF STRUCTURE pexfden,.Garage.C rnrnmrcial8ldg.Etc•.)Residence
IS USE: PRIMARY❑ SEASONAL❑ NUMBER OF BEDROOMS NUMBER OF BATHROOMS
HEATED STRUCTURE? YES 0+7role Bldg)0 YES(fart/s/oI etdg)❑ NO❑
DESCRIBE WORK New home for primary resisdence with two two unheated garages
J
�j S DARE FOOT :(prutxi.arJ1
IST FLOOR! sq.ft. 2ND FLOOR sq.ft. 3RD FLOOR sq.ft. BASE.MENT44W sq.ft.
DECK328 sq.ft. COVERED DECK sq.ft. STORAGE sq.ft. OTHER sq.ft.
74ZEC sq.11. Attached❑ Detached❑ C.WORT "° sq.ft. Attached 0 Detached❑
MANUFACTURED HOME L\FORVL�TION: % *4 COPIES OF THE L R PLAN REQUIRED*
MAKE MODEL YEAR LENGTH
WIDTH BEDROOMS BATHS SERLAL.NUMBER
ENVIRONMENTAL HEALTH:
SEW-AGE/SEWER SOURCE: SEPTIC❑ SEINER NEW E] EXISTING❑
PLUMBING IN STRUCTURE? YES I] NO❑ If yes,artaCh c•anrpleted Water Adequacy Faun
PERIMETER/FOUNDATION DRAINS PROPOSED? YES E] NO[] EXISTING SQ.FT.4022
EXISTING BEDROOMS PROPOSED BEDROOMS 3 TOTAL BEDROOMS 3
OWNER acknowledges that submission of inaccurate Information may result in a stop work order or permit revocation.Acknowledgement of such is by
signature below.I declare that I am the owner and I further declare that I am entitled to receive this permit and to do Ile work as proposed.I have
obtained permission from all the necessary parties,including any easement holder or parties of interest regarding this project. The owner or legal
representative•represents that the information provided is accurate and grants employees of Mason County access to the above described property
and structure(s)for review and inspection. This permit/applicabon becomes null&void if work or authorized construction is not commenced within 180
days or if construction work Is suspended for a period of 180 days.
PROOF OF CONTINUATION OF WORK ON THIS PERMIT IS BY MEANS OF INSPECTION. INACTIVITY OF THIS
PERMIT APPLICATION OF 180 DAYS OF MORE WILL CAUSE THE APPLICATION TO BE EXPIRED.(MASON
CO NTY CODE 14.08.42)
x •�/' 4/8/22
Signature of OWNER(Must be signed by the OWNER) Date f
DEPARTMENTAL REVIEW OVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANTING DEPARTMENT
FIRE MARSHAL
PUBLIC HEALTH
MASON COUNTY COMMUNITY SERVICES Permit No:*,bl6A?.t7Z2' b10'�'�
PERMIT ASSISTANCE CENTER:
•BUILDING .PLANNING .FIRE MARSHAL
I 615 W.Alder St-Shelton, WA 98584
j www.co.mason.wa.us
Phone Shelton:(360)427-9670 ext. 352• Fax:(360)427-7798
• / Phone Belfair:(360)275-4467• Phone Elma:(360)482-5269
PLUMBING & MECHANICAL PERMIT APPLICATION
OWNER INFORMATION: CONTRACTOR INFORMATION:
NAME:Earl Lincoln
NAME:Earl Lincoln Construction Inc
MAILING ADDRESS:P-o.Box 368 MAILING ADDRESS:P-o.Box 368
CITY:Belfair STATE:wA ZIP:98528 CITY:Belfair
1st PHONE:3so.8o1-+sao STATE:wA ZIP:98s2a
PHONE:360-801-1540 CELL:
"d PHONE: EMAIL :earluncolnconstn,otioninc@yahoo.con,
EMAIL::earllincolnconstructioninc@yahoo.com L&I REG#ccearlllc9+ogt EXP. 12 /19 /23
PARCEL INFORMATION:
PARCEL NUMBER (12 Digit Munher):12332-50-90851 Z011ing:R4
LEGAL DESCRIPTION (abbreviated):SAM B THELARS HOME&GAR TRAS TR 3"LOT A OF SP 92769 AF 9633236
SITE ADDRESS:321 weer creek In Belfair WA98528 CITY 6elfair
DIRECTIONS TO SITE ADDRESS:
Take Hwy 3 to Aldercreek In, go up rd to top of hill project site is on right at top
TYPE OF JOB:
NEW=ADDC]ALT=REPAIR=OTHER=USE OF BUILDING
LOCATION OF FIXTURES/UNITS—1IT FLOOR?ND FLOOR=BASEMENT=GARAGED OTHER
PLUMBING FIXTURES(SHOW NUMBER OF EACH) MECHANICAL UNITS
Type of Fixture No. of Fixtures Fees Fuel Type:Electric=LPGONatural Gas=Ductless=
Toilets -3-� Type of Unit No. of Units Fees
Bathroom Sink .3 Furnace + A
Bath Tubs + /.r Heat Pump +�-7�,/--
Showers + -- Spot Vent Fan 4 /
Water Heater Propane Tank
Clothes Washer 1 Gas Outlets
Kitchen Sinks 2 Wood/Gas/Pellet Stove
Dishwasher I Kitchen Exhaust Hood 1 _
Hose bibs 7 / Dryer Vent 1 /
Other Solar Panel 1�
Other
Base Fee Base Fee
TOTAL PLUMBING TOTAL MECHANICAL
OWNER acknowledge submission of inaccurate information may result in a stop work order or permit revocation.Acknowledgement of such is
by signature below.I declare that I am the owner,owners legal representative,or contractor.I further declare that I am entitled to receive this
permit and to do the work as proposed.I have obtained permission from all the necessary parties,including any easement holder or parties of
interest regarding this project.The owner or authorized agent represents that the information provided is accurate and grants employees of
Mason County access to the above described property and structure(s)for review and inspection.This permit/application becomes null&void
if work or authorized construction is not commenced within 180 days or if construction work is suspended for a period of 180 days. PROOF
OF CONTINUATION OFTHIS PERMIT IS BY MEANS OF INSPECTION.INACTIVITY OF THIS PERMIT APPLICATION OF 180 DAYS
WILL INVALIDATE THE APPLICATION.
x 4/8/22
Signature of Owner Date
DEPARTMENTAL REVIEW APPROVED DATE DENIED DATE TAGS/NOTES/CONDITIONS
BUILDING DEPARTMENT
PLANNING DEPARTMENT
FIRE MARSHAL
Rev:127/2016 JBN
1inz -_ APPROVED
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;�,11�,zEarl Lincoln �,a,.Cel � 12332-50-90851 BLD#h7IG12DZ?
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page 2 of 2)
Based Upon the information you have provided a Stormwater Site Plan IS Required for this development activity.
Title 14,Chapter 14.48 of the Mason County Code(MCC)regulates compliance requirements for Stormwater
Management in this jurisdiction.A complete copy of the ordinance can be found on the Mason County website:
hM//www.co.mason.wa—us/code/commissioners/index.htm
Please follow the links to"Title 14,Chapter 14.48 Stormwater Management".
Regulated activities shall be conducted only after Mason County Public Works approves a stormwater site plan
(Mason County Code Title 14 Chapter 14.48 section 14.48.70).You will receive a copy of the Public Works document
entitled "Managing Storm Drainage on Small Lots,The Small Parcel Stormwater Site Plan". This document will assist
you in preparing the necessary information and plans for Public Works to review and approve. Per Department of
Public Works this document will constitute an approved plan if all of the relevant details* are to be installed in
their entirety AND no part of the stormwater system adversely affects any septic system(see Environmental Health
information below). If an alternative system is to be used a plan will need to be submitted to Public Works for approval.
A design by a registered professional may be required for more complex sites.
*These details are found in the document Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan
on the pages that begin with"Handout"
PLEASE INITIAL BELOW TO INDICATE THE STORMWATER MANAGEMENT PLAN FOR THIS SITE
A) X The relevant details from Managing Storm Drainage on Small Lots, The Small Parcel Stormwater Site Plan will be installed
in their entirety AND the system will be located as not to adversely affect any septic systems on this,or any other,parcel.
and/or professional design will be submitted to the Department of Public Works for approval AND the
O?ll be located as not to adversely affect any septic systems on this,or any other,parcel.
If you have further questions pertaining to parcel drainage and stormwater management Mason County's Public Works
Department can provide additional instructions,guidance and examples. (Section 14.48.130)contact Public works at:
Phone: (360)427-9670 EXT.450
Mail:P 0 Box 1850,Shelton WA 98584
Physical:415 N 6th St, Shelton WA 98584
If this development has,or will have,a septic/drainfield system you may need to contact Mason County Division of
Environmental Health to ensure that the stormwater system will not adversely affect the septic system of this,or
any other,parcel.You may also wish to consult with the septic design professional involved with the project.Mason
County Division of Environmental Health can be reached at:
Phone: (360) 427-9670 EXT. 352
Mail:P 0 Box 1666, Shelton WA 98584
Physical:426 W Cedar St, Shelton WA 98584
A condition will be added to the building permit that states,in part,that all conditions the stormwater site plan will be met
prior to a request for final inspection of the building permit.
Owner/Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.I declare that I am the owner,owner's legal representative,or the contractor.I
further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above-
described roperty for review and ' tion as ma required.
X Owner gent/Contractor(circle one)Date: Z
Page 2 of 2
NameEarl Lincoln Parcel 12332-50-90851 BLD#
Mason County
Department of Community Development
Small Parcel Stormwater Management Application/Worksheet (page i of 2)
Per Mason County Code, Title 14, Chapter 14.48 a stormwater site plan is required whenever a building application is
made for residential development,or redevelopment',with more than 2,000 square feet of impervious surface2.
'Redevelopment means,on an already developed site,the creation or addition of impervious surfaces, structural development
including construction,installation or expansion of a building or other structure,and/or replacement of impervious surface that is not
pail of a routine maintenance activity,and land disturbing activities associated with structural or impervious redevelopment.
'Common impervious surfaces include,but are not limited to, rooftops,walkways,patios,driveways,parking lots or storage areas,
concrete or asphalt paving,gravel roads,packed earthen materials,and oiled,macadam or other surfaces which similarly impede the
natural infiltration of stormwater. Open,uncovered retention/detention facilities shall not be considered as impervious surfaces.
To Calculate Impervious Surfaces Please Complete This Table
Surface Type Length X Width = Area *All dimensions in feet
Buildings X
64 X 30 1920 Measurements for buildings are taken at the
X — perimeter of the farthest projections(example:
eaves/gutters)
X =
Driveways X
120 X 10 = 1200 Length of drive begins at the right of way
60 X 50 = 3000
Parking Areas X
X = Any paved, gravel or packed area per definition
above table
X =
Patios/Walks X =
6 X 18 = 1090 Any paved, gravel or packed area per definition
above table
22 X 10 = 220
Others X
X = If the total impervious area of the proposed site
X = development is greater than 2000 square feet a
Small Parcel Stormwater Site Plan is Required
Total Impervious Surface Area (sum of all areas)
If the Total Impervious Surface Area is LESS THAN 2000 Square Feet,please read, acknowledge and sign below.
Based Upon the information you have provided a Stormwater Site Plan IS NOT required for this development activity.
Owner Builder/Agent Acknowledges that submission of inaccurate information may result in a stop work order or permit revocation.
Acknowledgement of such is by signature below.i declare that i am the ov-ner,owner's legal representative,or the contractor.i
further acknowledge that the information provided is accurate and employees of Mason County are granted access to the above-
described property for review and inspection as may be required.
X Owner/Agent/Contractor(circle one) Date:
If the Total Impervious Surface Area is GREATER THAN 2000 Square Feet, please read,acknowledge and sign
the information provided on page 2 of 2.
Page l of 2
' BLD DATE STAMP
MASON COUNTY RECEIVED
COM %4UNITY SERVICES 21DZz- _-3
Building,Planr Environ mental Health,Community Health RCVD BY: AUG 08 2022
APPLICANT INFORMATION (please print clearly) ]A LJ JL AldeF Stret
Name of Applicant: Earl Lincoln Pa el Number: 12332-50-90851
Site Address: 321 Alder creek In Belfair WA 98528
This checklist must be completed and siguned by the owner or owners authorized agents at
time of submittal.
Incomplete applications will NOT be accepted. For a complete application, all items on this checklist
shall be submitted, unless waived by Staff.
PERMIT APPLICATION N/A Provided Staff
Provide a completed and signed(by owner or authorized representative)application ❑ 0
and applicable fees are due at submittal.
Provide a completed plumbina and Mechanical Application ❑ 0
SITE PLAN
Provide one(1)copy of proposed site plan. Drawn to scale of either ❑ 0
1"= 10' or 1"=20' depending on lot size.
North Arrow,location and dimensions of all property lines and easements. ❑ El
Vicinity map showing location and names of all roads and easements. (public and ❑ ❑
private)
Show distances to all structures; septic tanks,drain fields,property lines,top of ❑ ❑ j
slopes or cuts and easements. ✓
Zoning(indicate):
Rural Residential: ❑2.5 015 ❑10 ❑20 ❑Other:
Urban Growth Area:Low Densitv Resident Zone:R4
Front yard: Direction:w Side yard: Direction:n
Rearyard: Direction:a I Sideyard: Direction:s
All access points,width of access.(easements and driveways). ❑
Contour lines in twenty 20 foot increments. See Parcel Map Viewer on website ❑ 21
Building height shown on elevations at all four corners of structure. ❑ 0
Flood lain boundaries and setback distances. See Plans for additional requirements. 0
Wetland or surface water(if any) and any applicable buffers. If yes,a wetland
report may need to be submitted. ❑
Is the site near a Shoreline stream,creek, lake,saltwater)if yes,please indicate? ❑ ❑
00
Name of shoreline:
Shoreline designation:
Stream type F S Ns, N :
Is the proposed site within 300 feet of a slope 15%of greater?If yes,a geological ❑ ❑ S
report or assessment may be required.
Existing/proposed on= and eas, r idin back to ❑
structures. ]
-Existing/proposed wells show 100 ft well radius,with distances to structures).
Existing and proposed stormwater controls(downspouts,dry wells,etc. ❑ 0
Exterior stora4e tanks (propane) and HVAC ec ui meet. ❑✓ 1 ❑
AiMii
PLANS N/A Provided Staff
Provide three 2)copies of plans 1 full size min. 18"x 24"and 1 small size and ❑
two(1)copies of all specifications and engineering.Plans must be drawn to scale
of = 1'.All notations and drawings must be clear and legible.All Engineering ❑ ❑
callouts must be on plans.
Engineered plans must provide calculations/analysis.Analysis must include the
following information:
• 2018 International Building Code
• Snow load(by location) ❑ ❑ +�
• Seismic zone(D-2)
• Exposure (by location and topography)
• Wind speed 85 MPH basic and 110 ultimate w/3 secondgust)
If project is in a flood hazard area,the submittal must include an Elevation
Certificate,flood venting compliance and an elevation detail indicating the location 0 ❑ ) ,
of finished floor relative to the Base Flood Elevation or Design Flood Elevation as /J(j
designated by surveyor or engineer.
FOUNDATION PLAN
Plan view of foundation/footings/pads 00
Type,size and location of footing(stepped foundation provide detail ❑ ✓
Elevation view of foundation steps,with final grade ❑ 0
Cross-sections of footing and foundation(including height of wall). ❑
Floor joist andspacing each floor). ❑ 0
Show location of flood venting and detail the method and compliance for ventin . El ❑ 'Y
Type and locations of hold-downs and anchors. ❑ 0 t
Crawl access location and size. ❑
Insulation value for foundation(if slab or basement). See Energy Credits for ❑ 0
additional requirements,credits must be indicated on the plans.
If project is in floodplain provide flood venting compliance including vent
locations, vent type,elevation detail for venting location interior and exterior of the ❑ ❑ n/
crawls ace.
FLOOR PLAN
Square footage of each floor ❑
Use of each room ❑
'attic acces ❑
Dimensions of building and rooms. ❑ 0
Location and type of furnaces,water heaters,smoke detectors,and ❑ ❑
monoxide detectors.Include location of bollard for appliances located in garage.
Plumbing fixture locations ❑ ❑ I V1—
Location of doors,windows include size,egress,tempered andskylights) I ❑ El
Insulation value in floor. See Energy Credits for additional requirements, must be ❑ ❑ f
indicated on the plans. 7
Location of ventilation fans and CFM for each. ❑ ❑
Location of whole house lan and CFM (continuous or intermittent) ❑ ❑
Location,side and type of brace wall or shear-wall panels. If structure is ❑ 0 l
engineered,must supply two copies of required analysis calculations
Dimensions andoponOWPOtails of de4o(including joists,beams,posts,ledgers. ❑ 0
Plan MUST include size,grade, spacing,length andspecies or type of material)
ELEVATIONS AND WALL DETAILS
Typical and rated walls(garage separation) ❑
Listing of fire-resistive wall designs(duplex or townhouse) ❑ ❑
Building elevations-all 4 sides Show distance from grade at each comer. ❑ 0
Exterior wall details when distance between overhangs is less than 5 feet. ❑ CI
Insulation value for walls.See Energy Credits for additional requirements,must be ❑
indicated on the plans.
If project is in floodplain must provide Elevation detail indicating the location of ❑ ❑ n/)
finished floor relative to the Base Flood Elevation or Design Flood Elevation as
designated by surve or or engineer. ❑
ROOF PLAN
Layout of roof system ❑ �
Label type of roots stem,rafters,engineered trusses&spacing
❑ 0
;Rc
aders noted at each location or typical header noted. ❑ E]
of itch and coveringmaterials ❑ 0
eathin es, dimensions and fasteuin ❑ ❑
tic ventine( e, location and amount) ❑ Qsulation value for roof(R38 vault and R49 ceiling) See Energy Credits for ❑
addition rec uirements, must be indicated on the plans. Es
ENERGY CODE REQUIREMENTS N/A Provided Staff
Completed Washington State Energy Code form ❑ ❑
Plans must indicate fuel source for furnaces,water heaters and other appliances. ❑
Manufactures Specifications for each unit or component for HVAC&plumbing ❑ ❑ t�
Compliance to the Washington State Energy Code and required Credits.
Construction drawings/plans MUST include all credit information on the plan ❑
details such as insulation,ventilation,furnaces,windows etc. Plans must also
include the number of credits and which credits are chosen.
I verify that all required documents,plans, and specification associated with this application have been submitted and are
accurate.
Earl Lincoln 4/8/22
Signature of owner or authorized agent Print Name Date
CoL)
p 1 0 t J
A
Fn l►�-� l►� 2 0 I S
J
f MASON COUNTY Mason County Permit Center Use:
COMMUNITY SERVICES ADv
Building,Planning,Environmental Health,Community Health
615 W.Alder St.—Bldg.8,Shelton,Wa 98584 Date Rcvd
Phone:(360)427-9670 ext.352♦Fax:(360)427-7798
Fee: $130.00
Request for Administrative Variance for
Reduction in the Required Setbacks
For administrative review, the minimum variance on a setback request is 5 feet from the side yard lot
lines and 10 feet for front and rear lot lines or any access easement. Request for further rgcgct
requires a standard variance. Setbacks are measured from the furthest projec �t
including roof eaves and gutters.
-AUG 0 8 2022
Applicant/Owners: �t.t L Li n co I h J.
.� T2nX 31Q Mailing Address: ? 2) 61'5 W. Alder Street
r. 1
City: ��(,I �G,llL� State: W�. Zip: �t 85 2.
Telephone: 3AO.601 - l siqn 538So
Email: O ,a'I l nGb1 r-1 601'1 SAT11 .,rhOy A C(i)I oD, 6 6 M
If this reduction is tied to a building permit,please give permit case number.
BLD D ZZ - 010:3
Parcel Number(s): I a3�a 'Jr�' qd S ( Zoning'
Site Address: 4m— 6igm=m. LL AP—, -1,rn
Requested setback variance:
ID—ft. Front ❑ Rear ❑ Side
ft ❑ Front ❑ Rear ❑ Side
ft. ❑ Front ❑ Rear ❑ Side
ft ❑ Front ❑ Rear ❑ Side
Front Seticks—From access easements and road right of ways. Minimum 10 feet.
Rear Setbacks—From the rear property line. Minimum 10 feet.
Side Setbacks—From the side property line. Minimum 5 feet except for certain shoreline designations.
An illustrated site plan is required.
Your site plan must show the following: north arrow, abutting street or easements, and set backs to all
property lines and existing buildings, slopes, surface water,wetlands, critical areas, septic, well and
driveway. Show all proposed new development.
1
f` F ON AND OR REAR YARD REDUCTION RE VESTS:
F r e ' ting lots of record as of March 5, 2002;
You must meet one of the following:
1) One of the following exists on the lot(check all that apply):
Xa) steep slopes,wetlands, or streams present;
❑ b) soils that restrict building or septic development;
❑ c) lot width at the front yard line of no more than 50 feet;
❑ d) lot size of no more than one-fourth acre;
❑ e) existing improvements of buildings, septic systems, and well areas.
SIDE YARD REDUCTION REQUESTS:
For existing lots of record as of March 5, 2002;
You must meet one of the following:
2) One of the following exists on the lot(check all that apply):
❑ a) steep slopes,wetlands, or streams present;
❑ b) soils that restrict building or septic development;
❑ c) lot width at the front yard line of no more than 50 feet;
❑ d) lot size of no more than one-half acre;
❑ e) existing improvements of buildings, septic systems, and well areas.
Explain how these circumstances preclude a reasonable development proposal from meeting the
setback standard for Rural Residential 2.5, 5, 10, or 20 zones.
_Du�_7 ta -10 -R4_t_?6&6L
Owner/Agent(please indicate)
Signature Dat
Official Use Only
Approved by: Date
Denied by: Date
Reason for denial: