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HomeMy WebLinkAboutApplication.pdfGarfield County Community Development Department 108 8th Street, Suite 401 Glenwood Springs, CO 81601 (970) 945 -8212 www.t;arfield- countv.com BUILDING PERMIT APPLICATION TYPE OF CONSTRUCTION n Commercial /Multi - Family • Demolition C Residential (SF, Duplex, orTownhome) • Reroof ❑ Manufactured Home (SF or Duplex) Grading (locate all utilities prior to grading) INVOLVED PARTIES Property Owner: AJ ff Mailing Address: /.2U &TA ,/,76 Contractor: 4 'e41 CO .4ra1/4.1.ra t.:O.J 6-.C3'‘ C /g. 23/ Mailing Address: Phone: (9,74 )�s'5 ='%x G'W5, co K--/do/ (ittftei)fletikfeAkrnehipscl\, Phone: (77c7 ) 8,7t- -/yy3 Architect: Phone: ( Mailing Address: Engineer: Phone: Mailing Address: Manufactured Home Installer: Phone: Mailing Address: PROJECT NAME AND LOCATION Describe Work: 4044t/ oli'at h / .LPVe /'y5 Job Address: h'Y7G �/418 81 Hw y ib/ �rasArmer 99/ Assessor's Parcel Numberaia'.335 /, v' 8' Sub. Owner's Valuation of Work: $ Sq.Ft of Building: Height: ❑ New 0 Alteration ❑ Addition 6,), z!& &' 2/ Lot ,r /4 Block Property Size (Sq.Ft or Acres): Class of Work: # of Floors: ❑ Repair Garage: ❑ Attached Septic: ISDS Type of Heat: ❑ Natural Gas Driveway Permit: ❑ Exempt 0 Move /Relocation ❑ Detached ❑ Propane ❑ Community ❑ Electric ❑ Other O Permit #: Grading Square Feet of Earthwork •2s % Cubic Yards of Earthwork NOTICE Authority. This application for a Building Permit must be signed by the Owner of the property, described above, or an authorized agent. If the signature below is not that of the Owner, a separate letter of authority, signed by the Owner, must be provided with this Application. Legal Access. A Building Permit cannot be issued without proof of legal and adequate access to the property for purposes of inspections by the Building Division. Other Permits. Multiple separate permits may be required: (1) State Electrical Permit, (2) County ISDS Permit, (3) another permit required for use on the property identified above, e.g. State or County Highway/ Road Access or a State Wastewater Discharge Permit. Void Permit. A Building Permit becomes null and void if the work authorized is not commenced within 180 days of the date of issuance and if work is suspended or abandoned for a period of 180 days after commencement. CERTIFICATION !hereby certify that I have read this Application and that the information contained above is true and correct. I understand that the Building Division accepts the Application, along with the plans and specifications and other data submitted by me or on my behalf (submittals), based upon my certification as to accuracy. Assuming completeness of the submittals and approval of this Application, a Building Permit will be issued granting permission to me, as Owner, to construct the structure(s) and facilities detailed on the submittals reviewed by the Building Division. In consideration of the issuance of the Building Permit, I agree that I and my agents will comply with provisions of any federal, state or local law regulating the work and the Garfield County Building Code, ISDS regulations and applicable and use regulations (County Regulation(s)). I acknowledge that the Building Permit may be suspended or revoked, upon notice from the County, if the location, construction or use of the structure(s) and facility(ies), described above, are not in compliance with County Regulation(s) or any other applicable law. hereby grant permission to the Building Division to enter the property, described above, to inspect the work. 1 further acknowledge that the issuance of the Building Permit does not prevent the Building Official from: (1) requiring the correction of errors in the submittals, if any, discovered after issuance; or (2) stopping construction or use of the structure(s) or facility(ies) if such is in violation of County Regulation(s) or any other applicable law. Review of this Application, including submittals, and inspections of the work by the Building Division do not constitute an acceptance of responsibility or liability by the County of errors, omissions or discrepancies. As the Owner, I acknowledge that responsibility for compliance with federal, state and local laws and County Regulations rest with me and my authorized agents, including without limitation my architect designer, engineer and/ or builder. I hereby acknowledge that I have read and understand the Notice and Certification above as well as have provided the required information which is correct and accurate to the best of my knowledge. Property Owner Print and Sign 1S. 113a['� C.?t1. o a //r:t Date f c� t� -140 3 OFFICIAL USE ONLY u�f! L! l dS , r2 //�,• per..,,�,�, ,� Special Conditions: fLSGL4 /L i i d x. 1 , ++'p C--,1 •�" ,I )`T2,O Sw ? cx 4'(u S 1 L /k /LtC z �g. /0 n v tji_ p,S' �j , a)ilig A0C7dl41, Misc Fees: Adjusted Valuation: Plan Check Fee: Permit Fee: Manu home Fee: Total Fees: Fees Paid: lea. °° Balance Due: BP No: ISDS No: 'ARC- aA Setbacks: OCC Group: Const Type: Zoning: C BUILDING / PLANNING DIVISION : —' 411 Signe. Approval Date NOTICE -` Authority. This application for a Building Permit must be signed by the Owner of the property, described above, or an authorized agent. If the signature below is not that of the Owner, a separate letter of authority, signed by the Owner, must be provided with this Application. Legal Access. A Building Permit cannot be issued without proof of legal and adequate access to the property for purposes of inspections by the Building Division. Other Permits. Multiple separate permits may be required: (1) State Electrical Permit, (2) County ISDS Permit, (3) another permit required for use on the property identified above, e.g. State or County Highway/ Road Access or a State Wastewater Discharge Permit. Void Permit. A Building Permit becomes null and void if the work authorized is not commenced within 180 days of the date of issuance and if work is suspended or abandoned for a period of 180 days after commencement. CERTIFICATION I hereby certify that I have read this Application and that the information contained above is true and correct. I understand that the Building Division accepts the Application, along with the plans and specifications and other data submitted by me or on my behalf (submittals), based upon my certification as to accuracy. Assuming completeness of the submittals and approval of this Application, a Building Permit will be issued granting permission to me, as Owner, to construct the structure(s) and facilities detailed on the submittals reviewed by the Building Division. In consideration of the issuance of the Building Permit, I agree that I and my agents will comply with provisions of any federal, state or local law regulating the work and the Garfield County Building Code, ISDS regulations and applicable land use regulations (County Regulation(s)). I acknowledge that the Building Permit may be suspended or revoked, upon notice from the County, if the location, construction or use of the structure(s) and facility (ies), described above, are not in compliance with County Regulation(s) or any other applicable law. I hereby grant permission to the Building Division to enter the property, described above, to inspect the work. further acknowledge that the issuance of the Building Permit does not prevent the Building Official from: (1) requiring the correction of errors in the submittals, if any, discovered after issuance; or (2) stopping construction or use of the structure(s) or facility (ies) if such is in violation of County Regulation(s) or any other applicable law. Review of this Application, including submittals, and inspections of the work by the Building Division do not constitute an acceptance of responsibility or liability by the County of errors, omissions or discrepancies. As the Owner, I acknowledge that responsibility for compliance with federal, state and local laws and County Regulations rest with me and my authorized agents, including without limitation my architect designer, engineer and/ or builder. I hereby acknowledge that I have read and understand the Notice and Certification above as well as have provided the required information which is correct and accurate to the best of my knowledge. 7 C &TZ/ rF Property Owner Print and Sign - � I '? I �f'1 O 9.6 ° Date / OFFICIAL USE ONLY "d q'TI Lj ll FC 3 ra. Special Conditions: -I,i li...6 f1 ""ALL AiSP-L-6441 G�S MP Ci:)l.e-ix&L X1,0 5icy/ 4 %i 4'f-U S-` )8 r- /k /?4Ci a /) AAA, �✓�40.5, al,157- 1 IOC7c1S/� s:. Mises Adjusted Valuation: Plan Check Fee: P{errmmiitt Fee: L M anu home Fee: Total Fees: 4.,((0 Fee a — 1/ „0. Balance Dui: /icy+{ Bp No: 15D5 No: --c2Pnr) Setbacks: OCC Group: Const Type: Zoning: c/.... BUILDING / PLANNING DIVISION : A 11111 �/ 4, loi 3 Signe. Approval Date Cu At(' STATE OF COLORADO Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Denver, Colorado 80246-1530 Phone (303) 692 -2000 TDD Line (303) 691 -7700 Located in Glendale, Colorado http://www.cdphe.stale.co.us Colorado Department of Public Health and Environment For Agency Use Only Permit Number Assigned COR03- Date Received / Month Day Year COLORADO DISCHARGE PERMIT SYSTEM (CDPS) STORMWATER DISCHARGE ASSOCIATED WITH CONSTRUCTION ACTIVITIES APPLICATION PHOTO COPIES, FAXED COPIES, PDF COPIES OR EMAtLS WILL NOT BE ACCEPTED. Please print or type. Original signatures are required. All items must be completed accurately and in their entirety for the application to be deemed complete. Incomplete applications will not be processed until all information is received which will ultimately delay the issuance of a permit. If more space is required to answer any question, please attach additional sheets to the application form. Applications must be submitted by mail or hand delivered to: Colorado Department of Public Health and Environment Water Quality Control Division 4300 Cherry Creek Drive South WQCD -P -B2 Denver, Colorado 80246 -1530 Any additional information that you would like the Division to consider in developing the permit should be provided with the application. Examples include effluent data and/or modeling and planned pollutant removal strategies. PERMIT INFORMATION Reason for Application: © NEW CERT 0 RENEW CERT EXISTING CERT # Applicant is: ill Property Owner CI Contractor /Operator A. CONTACT INFORMATION - NOT ALL CONTACT TYPES MAY APPLY * indicates required *PERMITTEE (If more than one please add additional pages) *ORGANIZATION FORMAL NAME: New Creation Church 1) *PERMITTEE the person authorized to sign and certify the permit application. This person receives all permit correspondences and is legally responsible for compliance with the permit. Responsible Position (Title): Pastor Currently Held By (Person): Mark Bfntliff Telephone No: 970- 945 -5902 email address pastormark @newcreationchurch.org organization: New Creation Church Mailing Address: P.O. Box 1996 City: Glenwood Springs state: CO Zip: 81602 This form must be signed by the Permittee (listed In item 1) to be considered complete. Per Regulation 61 In all cases,, it shall be signed as follows: a) In the case of corporations, by a responsible corporate officer. For the purposes of this section, the responsible corporate officer is responsible for the overall operation of the facility from which the discharge described in the application originates. b) In the case of a partnership, by a general partner. c) In the case of a sole proprietorship, by the proprietor, d) In the case of a municipal, state, or other public facility, by either a principal executive officer or ranking elected official page 1 of 5 revised April 2011 2) DMR COGNIZANT OFFICIAL (i.e. authorized agent) the person or position authorized to sign and certify reports required by the Division including Discharge Monitoring Reports'DMR's, Annual Reports, Compliance Schedule submittals, and other information requested by the Division. The Division will transmit pre - printed reports lie. DMR's) to this person. If more than one, please add additional pages. Same As 1) Permittee Responsible Position (Title): Currently Held By (Person): Telephone No: email address Organization: Mailing Address: City: State: Zip: Per Regulation 61 : All reports required by permits, and other information requested by the Division shall be signed by the permittee or by a duly authorized representative of that person. A person is a duly authorized representative only if: (i) The authorization is made in writing by the permittee (ii) The authorization specifies either an individual or a position having responsibility for the overall operation of the regulated facility or activity such as the position of plant manager, operator of a well or a well field, superintendent, position of equivalent responsibility, or an individual or position having overall responsibility for environmental matters for the company. (A duly authorized representative may thus be either a named individual or any individual occupying a named position); and (iii) The written authorization is submitted to the Division 3) SITE CONTACT local contact for questions relating to the facility & discharge authorized by this permit for the facility. Same As 1) Permittee 0 Responsible Position (Title): Currently Held By (Person): Telephone No: email address Organization: Mailing Address: City: State: Zip: 4) * BILLING CONTACT if different than the permittee Responsible Position (Title): Currently Held By (Person): Telephone No: email address Organization: Mailing Address: City: State: Zip: Page 2 of 5 revised April 2011 5) OTHER CONTACT TYPES (check below) Add pages if necessary: ResponsiblePosition (Title): Engineer Currently Held By (Person): Gregory Shaner Telephone No: 970.625.4933 email address shaner @coloradorivereng.com Organization: Colorado River Engineering, Inc. Mailing Address: PO Box 1301 City: Rifle o Pretreatment Coordinator a Environmental Contact o Biosolids Responsible Party o Property Owner State: Colorado Zip: 81650 ❑ Inspection Facility Contact R) Consultant ❑ Compliance Contact B. Permitted Project/Facility Information Project/Facility Name New Creation Church ❑ Stormwater MS4 Responsible Person ❑ Stormwater Authorized Representative ❑ Other Street Address or cross streets 44761 Highway 6 (e.g., "S. of Park St. between 5th Ave. and 10th Ave. ", or "W. side of C.R. 21, 3.25 miles N. of Hwy 10 "; A street name without an address, intersection, mile marker, or other identifying information describing the location of the project is not adequate. For linear projects, the route of the project should be described as best as possible with the location more accurately indicated by a map.) City, Glenwood Springs Zip Code 81601 County Garfield Facility Latitude/Longitude — (approximate center of site to nearest 15 seconds using one of following formats 001A Latitude Longitude (e.g., 39.703 °, 104.933 °) degrees (to 3 deci▪ mal places) ▪ degrees (to 3 decimal places) or 001A Latitude 39 ° 34 ' 21 " Longitude 107 ° 27 ' 33 " (e.g., 39°46'11"N, 104°53'11'W) degrees minutes seconds degrees minutes seconds For the approximate center point of the property, to the nearest 15 seconds. The latitude and longitude must be provided as either degrees, minutes, and seconds, or in decimal degrees with three decimal places. This information may be obtained from a variety of sources, including: o Surveyors or engineers for the project should have, or be able to calculate, this information. o EPA maintains a web -based siting tool as part of their Toxic Release Inventory program that uses interactive maps and aerial photography to help users get latitude and longitude. The siting tool can be accessed at www.epa.govitri/report/siting_tool/index.htm o U.S. Geological Survey topographical map(s), available at area map stores. o Using a Global Positioning System (GPS) unit to obtain a direct reading. Note: the latitude /longitude required above is not the directional degrees, minutes, and seconds provided on a site legal description to define property boundaries. C. MAP (Attachment) If no map is submitted, the permit will not be issued. Map: Attach a map that indicates the site location and that CLEARLY shows the boundaries of the area that will be disturbed. Maps must be no larger than 11x17 inches. D. LEGAL DESCRIPTION Legal description: If subdivided, provide the legal description below, or indicate that it is not applicable (do not supply Township /Range /Section or metes and bounds description of site) Subdivision(s): Lot(s): Block(s): OR El Not applicable (site has not been subdivided) page 3 of 5 revised April 2011 E. AREA OF CONSTRUCTION SITE Total area of project site (acres): ±16 Area of project site to undergo disturbance (acres): ±g Note: aside from clearing, grading and excavation activities, disturbed areas also include areas receiving overburden (e.g., stockpiles), demolition areas, and areas with heavy equipment /vehicle traffic and storage that disturb existing vegetative cover Total disturbed area of Larger Common Plan of Development or Sale, if applicable: (Le., total, including all phases, filings, lots, and infrastructure not covered by this application) Provide both the total area of the construction site, and the area that will undergo disturbance, in acres. Note: aside from clearing, grading and excavation activities, disturbed areas also include areas receiving overburden (e.g., stockpiles), demolition areas, and areas with heavy equipment /vehicle traffic and storage that disturb existing vegetative cover (see construction activity description under the APPLICABILITY section on page 1). If the project is part of a larger common plan of development or sale (see the definition under the APPLICABILITY section on page 1), the disturbed area of the total plan must also be included. F. NATURE OF CONSTRUCTION ACTIVITY Check the appropriate box(s) or provide a brief description that indicates the general nature of the construction activities. (The full description of activities must be included in the Stormwater Management Plan.) 1 1 • 1 Single Family Residential Development Multi - Family Residential Development Commercial Development Oil and Gas Production and /or Exploration (including pad sites and associated infrastructure) Highway /Road Development (not including roadways associated with commercial or residential development) Other — Description: Church rough site grading G. ANTICIPATED CONSTRUCTION SCHEDULE Construction Start Date: Q5107/2013 Final Stabilization Date: 10/31/2013 •Construction Start Date - This is the day you expect to begin ground disturbing activities, including grubbing, stockpiling, excavating, demolition, and grading activities. 'Final Stabilization Date - in terms of permit coverage, this is when the site is finally stabilized. This means that all ground surface disturbing activities at the site have been completed, and all disturbed areas have been either built on, paved, or a uniform vegetative cover has been established with an individual plant density of at least 70 percent of pre - disturbance levels. Permit coverage must be maintained until the site is finally stabilized. Even if you are only doing one part of the project, the estimated final stabilization date must be for the overall project. if permit coverage is still required once your part is completed, the permit certification may be transferred or reassigned to a new responsible entity(s). H. RECEIVING WATERS Of discharge is to a ditch or storm sewer, include the name of the ultimate receiving waters) Immediate Receiving Water(s): Ditch Ultimate Receiving Water(s): Colorado River Identify the receiving water of the stormwater from your site. Receiving waters are any waters of the State of Colorado. This includes all water courses, even if they are usually dry. If stormwater from the construction site enters a ditch or storm sewer system, identify that system and indicate the ultimate receiving water for the ditch or storm sewer. Note: a stormwater discharge permit does not allow a discharge into a ditch or storm sewer system without the approval of the owner /operator of that system. page 4 of 5 revised April 2011 L REQUIRED SIGNATURES (Both parts i. and ii. must be signed) Signature of Applicant: The applicant must be either the owner and /or operator of the construction site. Refer to Part 0 of the Instructions for a dditionaf Information. The application must be s+gned by the applicant to be considered complete. in all cases, It shall be signed as follows: (Regulation 61.4 (lei) a) In the case of corporations, by the responsible corporate officer is responsible for the overall operation of the facility from which the discharge described in the form originates b) In the case of a partnership, by a general partner. c} In the case of a sole proprietorship, by the proprietor. d) In the case of a municipal, state, or other public facility, by either a principal executive officer, ranking elected official, (a principal executive officer has responsibility for the overall operation of the facility from which the discharge originates ), STOF t: A Storrnwater Managemerr Plan 'rus be itorl ted > for to si rail t wi I i. STORMWATER MANAGEMENT PLAN CERTIFICATION "1 certify under penalty of law that a c tnpiete Sio)mwater Management Plan, has been prepared for my activity. Based on my Inquiry of the person or persons who manage the system, or ose p rsoyt's,directly responsible for gathering the information, the 5tormwater Management Plan Is, to the best of my knowledge and belief , true, ac r t� and complete. c plete. I am aware that there are significant penalties for falsely certifying the c mpletion of said SWMP, including the possibility`of fine a rison ant for knowing violations." _ ,✓ XX f; Signature of e Name (printed) ibie P sons Authorized ::ent (submission must Include original signature) Title li. SIGNATURE OF PERMIT LEGAL CONTACT "I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the Information, the information submitted Is to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations." "I understand that submittal of this application is for coverage under the State of Colorado General Permit for Stormwater Discharges Associated with Construction Activity for the entirety of the construction site /project described and applied for, until such time as the application is amended or the certifications. an ferred,In. `_ ired." 1 A .rA1Ti 5' nature of Legally Responsible P /.n (submission must Include original signature) /1/4P-k , > ! MI-41 R, ivWNr Name (printed LT % —S Date Signed Title DO NOT INCLUDE A COPY OF 11* STORMWATER MANAGEMENT PLAN DO NOT INCLUDE PAYMENT — AN INVOICE WILL BE SENT AFTER THE CERTIFICATION IS ISSUED. page 5 of 5 revised April 2011