OCTOBER 18 2016 BUILDING APPSAPPLXCArIC'T TYPE: RESIOEIITIAL Ad5-ef+1 l"i;;r--.*t"
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PROPCRTY (x.lER'S
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CITY:
CITY:
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EI'IAII. ADDRESS:
"PTEASE CII€CX AtO A'I'IER SELO' ALL T]UIT IPPLY TO \.(I,A PRO]ECT:
I rrr erust
-
sF I otr caucr
-
sF tr FoRclt _sF
$sunnoor /'/4 sc n Pfi}L SF tr sToR 6E SHED
-
sF
tr GREENXOISE
-
5F ! oecr 5T OTHEi:SF
No
LI DUPLEX LJ I@INHOUSE Vl $?
ION
Yes
Sc.ul.,.t
o, ciaue rn (an r&D. ct
O roraL se FT ultDER L AREA sQ n: / /cti. 4
TOrAL PROIECT COST tLes.rdr :g li,ono or *
I5 AIIY ELECTRICAL'PUrtfIrJG or tlECHr tc^! Uo.k Belng Done to the a((eiso'y Stru(turt)BG' n
If the p.lject ls a Relocatlon,ls there a Natural Gas Llne on the Cu"ent Sltel n
eoJr',/14 ti;non
o, ,roarrr,l9r,Ftt
I5 the.e €lectrl(.I Por,er on th ls euitdlng? fiYes E
PROPER'Y UsE / OCO'PANCY:SINGLE FAIitII.Y
OESCRIPTIO OF }ORX:
'lorr!
bmrurn !l lnl!r.! conDlt e6l lro sbto codo ard o! oti9l @tt!6t s!at! d/!ll baol
md orddtE! 6c, 'lgrr8rl,!TrE ilrrc Ootrngitrsnl S.rtE . ConErt{t Do m,rod ol 3^t d'rgo. ! tro.p,,o
b Ffu6 Lblos5@qr"ao.n o, 6bmat .t "',{OIE: M,PllD3 n Vabbi oltn. NC Snrl
O{NEn/CoilTRACToR I SIGI{ATURE:
. r...l. r...trrt *... r..a... J3 a. r.r. rrratatraaa aara ita a.I
rs rHE PRoPERTY LOCATED rt{ A Ft@DPLArill E YES [t nO
EXrsTr!5 Ir@ElWCtts Ntar\t /'L/ ll iQ Ff TOTAL ACRES DT5TUnBED: fu /n'
r{EH rlpEnEqrs
^aEA Jl/LsQ Fr Exrsr LA D orsrunsrllc pemrr: l--l v:s l--'] m
turen, El'crrur ! comurrrv svsrer'r ! pnwarE gELL ! ce xrRau xett
se*n: ffifcreua ft cerrnal seprrc E p(rvirE sEPTIc ! comllrrv svsren
,.. sE?aaATE PETFTITS nEO.rrRtO tO8 ELECT, nt(X, PLa6, CAS €qJIp, Pn[tA8S I ]|6€nTS'.'
*'Lr.:rri..,.E.fl..trT.1T.::l:T.'i.:.iT].F.fi11L:y.:11i...E.Y.T:....9."',::r
(ror orfr(a lrs{ o/rY) irvltao o^ra a]l/tr/t2
zolE : _ oFFICER:' SEIBACKs: F; LH: RH: Bi
Approval._ City:_ DATE:_ FL@o: _ BFE+2ft= _..J a v I
I
Cqinent:PERflIT TEE: ,-
ZIP i
TOTAL HEATED SQ FT:
PRO]ECT CO TACT PERSOI;
EXrSTIllG Cot{Snucrro : E aLTERATTOII
nEI CO{STRI CTro{: I raecr EH REsrDEtacE or E firrro* m ExtsrrNc REstoEltcE
No
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RECETVED OCI1r 1015
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NEW HANOVER COUNTY EUIIOING PERMIT
APPL, A1ON fY PE : RESTDENnAL
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AppLtcAtrT,s NAME! Hsnry Dopaw D e, 10/lz20t6
PSOJECT ADoRESST 2 512 Sound Loop Road cn1,. VMlmington atP.28r'11
sugorvrstoN:loT lr 38
s 595 6107 +a]4 - 8881pRopfn1y ow1ERt NAruE. Tonielynn and Henry Oepew
Owr{ER,s ADDR€ss: 725 E Kingston Avo
@
PHONE f: 41
6;n. Chadoile ltP
CONIRACIOR:J r
A
D
AOORESS:
- EMAII AODRESS:
( Suoroorn (SF)lq'1
0 G/€.nhouse {sFl _ tr De(l (SF}_
15 the propos€d worl chanttnt the erlstlnt footprlnt? O ye, 0 No
IOTAI 5q FT UNDEi [OOt Aot pmposed workl |leated: O
I TOTAL PROJECT COST (ter3 Lot):91ooo
Property us€/ Occupancy: 6 Slngle Fam lly tr Townhou*
ls lh. propolld wo.l chrngtng tha numbe.o, bedrooms? 0 yer fffols.nytlcctrlc.l.ptumblntorMachank:tworkbetngdonetothcAccersorystruduretryssBNo
lftheprojestkaRlloEator,lsthrr!aNatunl6asl,insonthEcurrantsiteiEyrrOwo
ls the.e Eleqtrical Pow.. on this guildthg? E y6 E No
r
CITY:
unhcatcd: /?9 ?o'c\
PHOtlt; 4t{<- ot )
Eqg-6/o-7
O Porch (SF) _.-=.-
D StoraBr Shed (SF)_
E Orh€r tsFt
- PiOJECT COI'ITACT PERSON:PHONE:E
EXIi'|NG CONSTIUCT|OT{I O Alteratlon B lenov.tlon E GeneratNcprl.s
NEW Cor{5mufiroll: E tr€ct t{ew Residcn.e E Addirronro Ersurg Residen.e o nerocarron
...PTEIST CHECNAND Ai'SWER gErOW AI.,I" TI{AT APPTY TO YOt'R PRo,ECT"'
E An Ga.ate (5t) _O Det Garage (SF) _
O Pool lsF)
-_
Oei<drllor olWorl!
4
aLl €6r,5 4/l 5a7aarr4 i1 forcll
OSEI tMtlr I h.r.hr c.rttyrh .[tit.t, orrn.lor! r0 lhB.rrlk don tr rafrlrt rnd aI r.ort wtU clrnr,y n4|h tieStrt Sulldlns Cad€ .nd Jl ot i.r appUcbta S!.ta and 10cal
laet ind ordln a net .nd rltulatloar. tnt flH C OGtloprnrnt Sarvi.., Cmtlr *ttr ba notlli?d o,.nydrn86 ln the.ppro4d gbnr md rpldnetbn! or ciant! in aonll.dorl^lorh.tton. . . .tOTt: Any wo.l 9.rro.rr.d *,lrtout tia tpprop.t t! oa.mtrr *1ll br h vat t loo ollh. C Strta gtr,! Code andrubrad to 0|tcr up to 53@s...
Owner/Conlrrcto.i Sl8n.tu!e:C'Uc.nted Quolifie/
ls rhe prorerty lo<ared tn a noodptatn? O vcs Efiro
Erlsunt tnpewlourArt", /4
Sq ft
I{rrrr lrnpErvlous ArG., d& ,o ,,
Totsl Acres Otrtu.bed: /A
tdsdri Laod Dlfttrbtng pcnnh: e yes E oWATER: E CFPUA El commsnlry sf/ste.n E p.tvate well 0 cantrd wql O equ:Sawti: g CFPUA D Communitysystlm E p.iv.te >i cEcentralsepticEAquaZona: Otfacn
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NEW HANOVER COUNTV BUIIDING PERMIT
APPUCAnON NPE: RESIDENTIAI
PI.CAS€ ANSWER AII- QUEsIIONS APPITCAELE TO YOUR PROJCCI
-Prole(t Rcspondbllly
JcriS-atql
Emall Prlnt
appll..tlon
Number
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APPUCAT{T'S NAME: H€Nry OEP€W oare. 1U1212016
PROJ€CT AD0R€sSl 2512 Middls Sound Loop Road clTy. VVilmington z/P.28/.11
LoT f: 38
s 595 6to7 +e]6 - 888?pRopERTy owNERB p4146, Tenielynn and Henry Oepew
g1ryx6r'5 1p9xg55' 726 E Ava
@
PXONE f;41
ClTy. Charlott€ztl.2g203
CONTRACTON:
ADDRESS:
BIDG IICENSE l:_
CITY ST: APIJ
aZ
,n
iUz
6o
B
- - EMAIL ADORESSI PHON€:
--7 PRoJECT COMACT PERSON:PHONE:
EXISTING CONSTRUCIIOT{: C Alteratlon G Renovation E General8epal6
NEIIU COI{SmUCI|O,{: E Ered New Residence O Addltion to Exlstint Residence 0 Relocatlon
...PI..EASE CHECI( AT{D AI{SWER BELOW AII. THAT APPTY TO YOUR PROJECT..'
O Att Garare (Sf)_ D Det Garage (SF) _ tr Porch (SF)_
( Sunroom (SF)I "111 D Pool(sFl
tr Deck (sF)
D Storage shed (sF)_
E Greenhouse (SF)_D other (sF) _
ls the proposed work changlng the existlng footprint? D Yes f] No
ToTAt sq Fr UNDER ROOF llor proposed wotkl xeared: O untreatea, /{t/ ?orc\
+ TOTAT PROJECT €OST (Less tot): S
j \ooo
ls the proposed work changing the numberof bedrooms? tr Ves (to
lsanyElectrlcal,PlumblntorMechanlcalworkbetntdonetotheAccessoryStructureEyesONo
lf the prorect lsa Relocstlon, ls there a NaturalGas Line on the curr€ntsite? E yes E No
lsthere Electrical Power on thls Bu ding? O yes O No
occupancy: 6 stn4e ramly O Townhouse
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3A
Z Prop€dy Use/
Oercriptlon ol
4
Wort: 04 o aL<4 t{1r.2 €bo ,s qdal Scteeacy't1 forctl
olsoAtMtR : I hereby aenfy rhat rll tiie lnformaion ln $t! aprltadon ls concct and all wort witl comrb wtth the Statc Buldhg Code and aI oth.r applloble Strte and to@tordlnan(et rnd ieSulatlon,.lhe NHC Oet€lopm€nt S€Mces Cent€r wfll ba notfled of anych.nSej ln the spproyed glanrand lpealllcattonr or rhange ln aontGcto.' OlE: Any wort p€.for'ried wtthout tie approrrt t€ leirlt, slll be tn vbbt lon o, the ttc State otdgCode and,ublect to ftne! u! to 9500.m...
Owner/Contractor:
'Ucensed Quoltlel
llc nrv Dcna z-,-t Slgnatura:c
TotalAcreJ Dtsturbed , N tX
Erlsdn8 Land Dtsturbtng permlc E yes E no
ls the property located tn a floodplaln? D Ves El'lo
Erlsdng lmperylour Are"r d4 Sq ,,
New lmpewlous ArG", dft ,o ,,
WATER: E CFPUA E Communtty System O private We[ E centlal Well E Aqua
SEWER: E CtpUA E Community Sfstem E privat€ Septic E Central Septic E Agua
zone: -- orfcer _ setbacb (F) _ (tH, _ (RH) _ (Br_
Approyat; _ Otyr_ Oate: _ Ftood: (A) _ M _ (N) _ SfE+2ft! .-__Comm€nti
Pernlt Fee: S
),m.'
(t ranrvt$.1iI.
NEW HANOVER COUNTY BUILDING PERMIT
APPLICATION TYPE; COMMERCIAL
PLEASE ANSIIJER ALL QUESTIONS APPLICABLE TO YOUR PR0IECT
"Project Responsibility"
J6rc'Y1a
L6-502
APPLICATION
Number
(office Use).o\-+\r(
!
-+.s
6-+t
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+
$
6
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APPLICANT'S NAiIE: Albert Eo:rr L DATE: n2/i3,2cl6
DEVELOPER: Bozart Brothers Ccns.ruction
CITY: i\, i 1m i ncr o.
PHONE #: -1ia54ir4r- l
ZIP i )9.4 -aPROIECT ADORESS: 6132 Jarorrnr Bedch F.d
OCCUPANT/ BUS I N E SS NAI\4E: .,,-.:..'. 7-::--
PROPERTY OWNER'S NAfilE: i.:.,.( :1r, 1 .-..1'
OWNER'S ADDRESS: .r4:5 Janice Lrne
Dentistr
:l inl
CfTY: wilmrnqton
PHONE #: rlL44i:9r'l
ST: NC ZIP:2841i
4;nar valili/CONTRACTOR: -r.,e Li,r z r rt LICENSE #: \a t 97 4052
ESS: Po Box 20
Et'lAI L ADDRESS: bi)zo.lall880ao L. conL
PROIECT CONTACT PERSON: r,,L,r .o. 1ri PHONE #: t 1c 5 4.n l4l8
(Check AIl That Apply)
EXIST CONSTRUCTION:ALTERATION RENOVATION GENERAL REPAIRS RE LOCATION
lf Relocation, is there a Natural Gas Line on the Current Site?Yes Em IS BLDG SPRINKLERED?[v". flno
NEW CONSTRUCTION:! enecr NEul srRUcruRE ! rrsr rRAcK E sHELL UPFIT ADD TO EXIST STRUCTURE
ACCESSORY STRUCTURE:
If UPFIT - The Shell Permit #:
IF Yes, vrhat was the Previous Occupancy lype?
ARCH DESIGN pROFESSIOiIAL: Nick Nve Ar.hirecr
ENGR DESIGN PROFESSIOTIAL: C.astal RiveI Engineeri..l
DESCRIPTION OF WORK:
Is Elect Power on this Building
***** rs rHrs A cHAr{GE oF occupANcy usE? flyEs flm ---..
T Yes Eruo
tlhat is the New Occupancy Type?
PH
PH
:9ll:i,iaa-r NC REG #:
:91115151:13 NC REG #:P-0791
ls food or beverages prepared or served in rhis structure? [ ves fl lo ls The Prop€rty Located ln The Floodflain? [ ves [l no
DISCLAIMER: I hereby cerUfy that all informatron in this appllcation is correcl and ali work will comply with the State Building Code and all other applicable State
dnd local ldws dnd ordirances and requlalions The NHC Develoomert Servrces Cenler will be notified of anv chanoes in the aooaoved olans and soecrficalrons
or chanoe in contractor or conlractor rhformatron. "'NOTE Any Work Perforned w/O lhe Approp'rate Permiis wrll bt in Viotati6n ol the NC Slate Bldg Code and
Sublectio Fines Up To $500 00"'
OWNERYCONTRACTOR: :,,,., -, ,,,:- ,.S;GNATURE: A"q/^j&x-t
(ou.rr@ (Pdnt Nam6) U
contaln Asbestos or not. You are r€quired to calllhe N8tional Emisslon Standards ior Hazsrdous Alr Pollubnfs NESHAP) Ef (919)707-5950 st l€s6t 10 doys fior to the
demolilion oI any facility or buildino. Seo A9b€stos Web Site: htts:/ /vww.6pi.stat6.nc.uy6pi/asbes0oyahmp.htnt
TOTAL PROJECT COST: I'!-o!-
TOTAL SQ FT UNDER ROOF: i T i .
ACRES DISTURBED: II
NEW IMPERVIOUS AREA: r
PROPERryUSE: @OrrrCe nResreunmrr lr'aencnr.rrlLe !
WATER: ZICFPUA
SEWER: 17 CFPUA
EcoMMUNtry SYSTEM fIWELL flzoNtNc usE CLASS|F|CAT|ON:
Ll CENTRAL SEpTtC Ll PR|VATE SEPIC fICOMMUN|TY SYSTEM
# OF STORIES: 1
EXST LAND DISTURBING PERMIT? N YES I NO
SQ FT EXISTING IMPERVIOUS AREA:
EDUC APT CONDO OTHER:
REVISED OATE 4/11/12
SO FT
"'SEPARATE PERMITS REOUIRED FOR ELECT, MECH, PLBG, GAS EOUIP, PREFABS & NSERTS *'
PAYMENT METHoD: ECASH ficuecx leeveBLE To NHc) finnlenrceru expRESS EMc /tsA E otscovER
(FOR OFFTCE USE ONLY)ZONE:_OFF|CER:-- SETBACKS: F:_LH: RH: B:Approval:_City:_DATE:_Flooo:_
- -are;fr:Commenl N
PERMIT FEE: $5l d,
&
CITY: Carolina Beach Rd ST: NC ZIP: 28428
PHONE #: 97a54at 41'7
BUILDING HEIGHT: ls #OFUNITS: L.5
TOTAL AREA SQ FT :-]]]:,1!_ SQFTPERFLR: 1E0.
# OF STRUCTURES: I # OF FLOORS: 1
NEId HANOVER COUNTY BUILDING PERII,IIT
APPLIoATIoN IYPE: COMiIERCIAL
PLEASE ANSIiIER Al-L QUESTIOI.IS APPIICABLE TO YOUR PROIECT
"Project Responsibility"
CL..(t,.t .*l ?.g'l 6J,-,Lo.'s, f,.c.
?uld1q?
APPLICATION
Number
(office Use)
APPLICANT,S NAI4E:
DEVELOPER:PHONE #:
PROIECT ADDRESS: Ll)) C "."1.,.d L CITY: \^Jil -.
occupANr/BusrNEss NAIi1E: B.z-t s--:\r D"J,t{-..
PRoPERTY owNER's NAiIE: fA(\.J Bo..l -J(.
EIIAIL ADDRESS: rf r{- e @)c li<,r.r-!ll - c., --r
zIP:e(qtl
prONE #: 716'2oo' t)r1 1
pHonr *r do- i5-.oSS{
PHONE *:11() -z?'- la'l t
otlNER'S ADDRESSt Cl32 C.-.1: -B.-"L Lf crTY: w.'t-;.,
coNrRAcroR: CL,^S(:.! ' !.!.1 c",1.-.{.,s LrcENsE *: I Sg2S r-rL
ADDRESS: 5,4)t c wlJ-.. r t C ITY:.t -;
tt sI tPL zIP| 2 9'lt2
ST : aJe zlp: 2.X46 S
PROJECT CONTACT PERSON:
Exrsr coNsrRucrrouppt'r-renrrrou I nemvnrror
lf Relocation. is there a Natural Gas Line on the Current Site? Ll
(check All That Apply)
GENERAL REPAIRS
Yes No IS BLDG SPRIN
RELOCATION
KLERED? [v"1,[ffi
NEw coNsrRucrror: f| enrcr NElr srRUcruRE ! resr rmcr I sxetpffuerrr ! aoo ro Exrsr srRUcruRE
ACCESSORY STRUCTURE:
If UPFIT - The 5hel1 Penmit f:Nl14
!',,i'',:i:* rs rHrs a cHAr,rGE oF occupaNcy usrl flves Ed*****
er.ffvu
po -a'k .,-n*i \. ot
IF Yes, uhat u,as the previous Occupancy Type?
ARCH DESIGN PROFESSIOML:
ENGR DESIGN PROFESSIOML:
Y<-
Is Elect Power on this Buildin
t'lhat is the Ne*, Occupancy Typel
IFICATION: 7. B
DESCRIPTION OF WORK: O J t:,,o Sl {r,ola o$$:.t a r
ts iood or bovsages p.epa.od ff sdved in this *uawe? [ "*EG ls Th€ Prop€rty Located tn The Ftoodflain? [ v*,[t-No
all other applicable State
olans and sDecficatrcns
NC Siare Bldg Code and
(Ou3liio4 enm Ndne)
tlolr: Dolnoliton noticatbn3 e a3b€3l6 rsnoyal psrhh applharions 616 to b€ submls.d urllt $o appllcation fonn (DHHS-3768)lhe fecility or buildlng wss fuund !o
conttln Asbosto6 or not You 616lEqulrod to call the Natonal Emlsslon Stndards fur Ha:€dous Alr PollulanB (NESHAP) st (S19)707-5950 al l6ssl 10 deys p.ior to the
d€nElhbn of any fadlhy o. buildlno. See Asb€3to6 Web She: hrpy re/w. epi.stete. nc. uyepi/asbesiorahmp. hlrnt
TOTAL PROJECT COST: ICA,, .AO BUILDING HEIGHT. P/tr # OF UNITS:rl 1l{-
TOTAL AREA SQ FT :ll qq <9 SQ FT PER FLR: iII # OF STORIES:
TOTAL SQ FT UNDER ROOF: I 'T 4 q <T # OF STRUCTU aes,{-# OF FLOORS
ACRES DISTURBED IA EXST LAND DISTURBING PERM
SQ FT EXISTING IMPERVIOUS AREA:
IT?NO
NEW IMPERVIOUS AREA:SQ FI
pRopERryUSE: flornce lnesraunnNr luencarrru leouc [eer lcoNoo ornen: D.-{, ( .$l.,re-
WATER:_ECFPUA
SEwER:-p.€FPUA EcoMMUNtTy SYSTEM IIWELL EZONTNG USE CLASSI |CENTRAL SEpTtC LJ PR|VATE SEpTtC fICOMMUN|TY SYSTEM
,o*.*,=,,J,'i$HHf,=Hlffi#Si,iJEffiffi l,:EH+:1"1u",,.o!o,scoven
ZONE:_OFFICER (FOR OFFICE USE ONLY)
SETBACKS: F:LH RH:B:Approval:_ City:_ DA _ BFE+2F
NComment
TE:_FLOOD:
REVISED DATE 41 1/'2
(]
l:l
/r/
oorr. 1o /, glt e
PH: 1i o'1Yo'JcC9ruc nee #. lo66 B
pa 4lilTllriTll Hc nrc *, o-5lTT5-
AL. 6 L-t t..
PERMIT FEE: $.-
,F
Zotklolll
NEw Hfred(furrtrr BUTLDTNG PERMTT
"Proiect Rasponsibility'
Prr*leri"s zLC
ua.a4q5
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#APPLICATION WPE.' RESIDENTIAL
PLTASE ANSWER ALt OUESIIONS APPTICABTE TO YOUR PIIOJ€CT
Date
PROJECT ADDR!ss: --D)-t -1.uc ctTY Lil L 2a t L.G .-; r' zp: _tZZ2!!3_
toT t:
CITY L^4
SUBDIVISION:, -
-PRoPIRTY OwNtR'S NAMt: _,<l4v iue PRc/({''?s r/Cpns71so tua-)2/-6836
OWNER'S ADDRESST ----,rL3-ztP: >?-/ t I
Swan SbnCONTRACTOB:
AODRESS:
BtDG LICENSE }
5T:-*D*L .. -'l-t I ,/h&10 N..,
EMAII- ADoREss: * 5--/4 i&)cl
ctw ztP
PROITCT CONTACT PERSON *tur D J-tr./
PHONE
7tc-221-63?L
/; (.
:i StoraBe shed (sF) ---
EXISTING COI{sTRUCTTON: i Alte.ation il fteilovation f-] Ge4eral Repairs
NEW coNSTRU€nONi X Erect Ner., Residen.o fl Addition to Existing Residence .j Relocation
-
..'qT+ASE CHECK ANO ANSWER BELOW AII THAT APPTY TO YOUR PROJESI"'
. .1 ;l\
Xarrca:rne{5F) l/ ' fl Det Garage (sr) --- :l Por.h (sF}
1... Sunrcorn (5F)
:-1 Greenhouse {SF} _---
A Pool(5t)
[] Deck lSF)./1 lo ,-,1 Orher (SF) _*,
ls the prcposed work changint the eri5ting footprlnt? I Yes al No
Jff U nhe.led:?)obrOTAL SQ FI UNotR ROOF':.'proposed workl HeAlAd
rorAt PRo'tcT cosr rtessto'l's /)0' c/ 09
ls the propo5ed work .hanBrnB the number of bedrooms? Bl yes X t'to
ls any tlect,ical, plumbiot or Mechanlcalwork bein8 done to the Accessory Structure I$ yes D No
lltheprojectrsaRelocalion,isthereaNaturalGasLineonthecurrenttite?OYesDNo
ls tl,p* €lectricalPower on thi5 Euilding? S Ves E r'to
Property use/ occupancy:.X singte tamily E Duptex E Townioute - ,;;;;1;"";;;;;: -'-i;A-
- bbv*AJcz|d!/ sl,/6tc Tu4)u (s t)rtr
DISCLAIM!R: r ncr(br r.'rili rh rll rhr rlormation in thrr rpp!l$1ion rJaorrad and,llwo,k wrurom9ly wrrh lheSralc 8(]rkj,ng Cod€.nd allothe.
li$s and ..Ciifter . nd ."f :r l.r'.n r. Tne NHC Oew!6trnen1 srrvrces Centcr willbe notifpd ol any.ha.gcr in th€.ppioved pla
r 1.,,.r1roa "'NOri anyr.,r9.r{n:-cdw(houlthenrrropristFptrdtswrllbelnvrolalionoltl{nc sry79z7 .t
-y)'/,'i-({,/( bJtlu _ Signature a.Owne./Contracto.:
'L)enteo Quohr?t'
It the ?:.perty located rn a f i.dplnrn? I yes &ruo
Exi5ting lmpervious A.u"r
--l-
So ,, Total Ac.es Disturbed
New lmpewious Area. -. ____ .__ Sg Ft fristing Land Disturbint Permiti E Yes ;l No
WATtn: E Cf DUA E Communrty System n Private Well n Central Well D eqr_ra
SEWER. ECFPUA O Communrry System D Private Septic I Central Septic E] Aqua
,on",R-|5ort,,,E f,t.Il,| setuacr<s{r}$/-(r.Ht l0' rant lC'- tat€i.>l
approvarr 0V - citv: L{.\.&{[ oate:ltl)Q Ftood: {A)
-
{v)- -- {N) 'X-8Fr+2ft= _- ,
Permit tee: S o..,","".'ilUllhry'LslQljj:ccl_.
APPUCANT'S NAMIi
?s-atto
, _, PHONE: