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Home My WebLink About20040767 CORRECTED RESOLUTION RE: ACTION OF THE BOARD OF COMMISSIONERS REGARDING WELD COUNTY CODE VIOLATION CASE VI #0300134 - LOYD AND SHEILA SCHLICHENMAYER WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, a zoning violation case, VI #0300134, was initiated by the Weld County Department of Planning Services against Loyd and Sheila Schlichenmayerfor alleged violations of the Weld County Code, and WHEREAS,on the 9th day of September,2003,a public hearing was held before the Board of County Commissioners for the purpose of hearing testimony relating to said violation, at which time the matter was continued to October 14,2003,to allow time for the Schlichenmayers to submit an application for a Site Specific Development Plan and Use by Special Review Permit ("USR"). The violation was not heard on October 14, 2003; however, it was rescheduled for March 9, 2004. WHEREAS,the Board of County Commissioners granted the Schlichenmayers USR#1450, with certain conditions, on February 18, 2004, and WHEREAS,on the 9th dayof March,2004,the Board considered the case and determined it best to refer the case back to the Department of Planning Services for follow-up on the conditions of USR #1450. NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County,Colorado,that VI#0300134 be,and hereby is,referred back to the Department of Planning Services for follow-up on the conditions of USR #1450. 2004-0767 PL0824 VIOLATIONS - VI #0300134 - LOYD AND SHEILA SCHLICHENMAYER PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 9th day of March, A.D., 2004. BOARD OF COUNTY COMMISSIONERS W LD COUNTY, COLORADO ATTEST: 0 �� EL,L 4 . �V � )/1 J4 1 � Robert D. Masden, Chair Weld County Clerk to th "o. -_ 1861 4. ., t---C' °'a"`, William H. Jerke, Pro-Tem BY: ' i Deputy Clerk to the B) 'U 1 EXCUSED M. J. Geile AP'-' • ` DAS • •. • EXCUSED David E. ong (minty A orne . -gag _____,L- Glenn Vaad il/Date of signature: 4° 2004-0767 PL0824 Weld County Violation Summary Compliance Officer Peggy Gregory BASIC INFORMATION Property Owner: Loyd and Sheila Schlichenmayer Violation: VI-0300134 Address: 5090 CR 1, Erie CO 80516 Legal: Lot B of RE-761 also known as part of the SW4SW4 of Section 6, Ti N, R68W of the 6th P.M., Weld County, Colorado Location North: South of Westview Estates Subdivision South: Residential/Agriculture East: Agriculture, Parkland Estates (3/4 mile) West East of and adjacent to CR 1 Parcel Number: 1467-06-3-00-004 Acres: 3 Certified mail date: August 13, 2003 Received: August 16, 2003 Currently the property is in violation of Chapter 23, Article III, Division 1 of Sections 23-3-20 and 23-3-30 and Chapter 29, Article VIII of Sections 29-3-320 OF THE Weld County Code. REMEDY Planning Staff met and determined there is no reasonable resolution under the Weld County Code. RECOMMENDATION The Department of Planning Services recommends that this case be referred to the County Attorney for immediate action. CASE HISTORY June 26, 2003 Initial complaint received. July 8, 2003 Violation letter issued. August 13, 2003 Letter sent to property owner indicating that the violation case was scheduled before the Board of County Commissioners. August 14, 2003 Phone call from Fred Otis, Attorney, to Kim Ogle, Lead Planner September 2, 2003 Letter from Fred Otis, Attorney 2004-0767 • :, s z b 3 t h 2 ..+x.' ':,.. *w "tea ,s, €d.t .. :"a`wa w,�;^. _ ..s `^ ''.-'[.4. t{ v,.. skr� f .aft h� vy. Y>`:• . i „.4.4„.4.4 •� �,ri� max,.+-,'n: � .:y,_ .�J� � »e � .��<... "T . , : z -�� !� v"» , k '. t 4 5c—..1� d^a 4� 1 dTG IY.'5,x • t tla "a • • A 4,, • 'j4' • Min". � } +F i 111 I. • (it DEPARTMENT OF BUILDING INSPECTION Code Compliance Division WWW. D.CO.US E-mail Address: pgregory@ry@co.co.weld.co.us 1555 N. 17th Avenue, Greeley, CO 80631 Phone (970) 353-6100x3540 Fax (970)304-6498 • COLORADO August 13, 2003 Loyd and Sheila Schlichenmayer 5090 CR 1 Erie CO 80516 Subject: VI-0300134 , Part of the SW4SW4 of Section 6, Ti N, R68W of the 6th P.M., Weld County, Colorado Dear Mr. and Mrs. Schlichenmayer: The property referenced above remains in violation of Chapter 29 of the Weld County Code. I have scheduled a meeting with the Board of County Commissioners on September 9,2003 at 10:00 a.m.,to consider the violations. The property is in violation of the following Section(s) of the Weld County Code: Chapter 23, Article III, Division I "A (Agricultural) Zone District" Section 23-3-20 "Uses allowed by right." Section 23-3-30 "Accessory uses." Chapter 29, Article VIII "Building Permits" Section 29-3-320 "Change in use." To bring your property into compliance with the Weld County Code: Planning Staff met and determined there is no reasonable resolution under the Weld County Code. This meeting will take place in the County Commissioners' Hearing Room, First Floor, Weld County Centennial Center, 915 10th Street, Greeley, Colorado. It is recommended that you or a representative be in attendance at this meeting to answer any questions the Board of County Commissioners might have regarding the violation. The Department of Building Inspection will be recommending that the Board of County Commissioners authorize the County Attorney to proceed with legal action to remedy the violation. Our records indicate that you were made aware of the nature of the violation,the action necessary to correct the violation,and that you were given sufficient time to remedy the violation. If you have any questions concerning this matter, please contact me at the above address, telephone number or e-mail address. rely, uy ( Peg c,regory 0 U Building Compliance Officer pc: VI-0300134 Fred L. Otis, Attorney at Law Wendi Inloes, Planning Technician Bruce Barker, County Attorney Kim Ogle, Planner III Bethany Salzman. Zoning Comeliance Officer U.S. Postal Service CERTIFIED MAIL RECEIPT (Domestic Mail Only: No Insurance Coverage Provided) M1 Ul a Postage $ C3 Certified Fee Return Receipt Fee Postmark (Endorsement Requires Here ru CI Restricted Delivery Fee p (Endorsement Required) @ Total Postage 8 Fees $ ru ltt Reciple 's Nam (Pi a Print Clear (To a completed by mailer) LayJ She& a__Sth cAenr 2.ye r Stree Apt.No.;or Po Box No. Ci ,5' 7,404CI_.I •S F.rm 3u t F .ruary 2n t Se Reverse r.r lnstructi.ns SENIE•: CSM•LETETHISSECTIsN C•M•LETETHISSECTI•N •N•ELIVE•V • Complete items 1,2,and 3.Also complete A. SI.•:tu item 4 if Restricted Delivery is desired. ' ■ Print your name and address on the reverse 0 Agent so that we can return the card to you. (Pt/ Addressee • Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Da =of D very or on the front if space permits. 1. Article Addressed to: D. Is delivery address diffensnt from item 1? - If YES,enter delivery address below: 0 No LOYD & SHEILA SCHLICHENMAYER 5090 CR 1 ERIE CO 80516 3. Service Type 10 Certified Mail ❑ Express Mae ❑ Registered 0 Return Receipt for Merchandise ❑Insured Mall 0 C.O.D. 4. Restricted Delivery?(Extra Fee) o Yes 2. Article Number (Transfer from servicelabel) 7000 0520 0025 0405 5782 PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 it;:e DEPARTMENT OF BUILDING INSPECTION Code Compliance Division Website: WWW.CO.WELD.CO.US IE-maii Address: pgregory©co.weld.co.us 1555 N. 17th Avenue, Greeley, CO 80631 Phone: (970) 353-6100,Ext. 3540 O Fax: (970) 304-6498 COLORADO WELD COUNTY • BUILDING CODE VIOLATION NOTICE July 8, 2003 Loyd and Sheila Schlichenmayer 5090 CR 1 Erie CO 80516 Subject: VI-0300134, Part of the SW4SW4 of Section 6,T1 N, R68W of the 6th P.M.,Weld County,Colorado Dear Mr. and Mrs. Schlichenmayer: It has been determined that the property located at 5090 County Road 1 is currently in violation of the following Section(s) of the Weld County Code: Chapter 23, Article Ill, Division 1 "A(Agricultural)Zone District" Section 23-3-20 " Uses allowed by right." Section 23-3-30 "Accessory uses." Section 23-3-40.L "Uses by special review." Chapter 29, Article VIII "Building Permits" Section 29-8-40 "Expiration of permit." Section 29-3-320 "Change in use." To bring your property into compliance with the Weld County Code: All necessary inspections shall be completed and the permit shall have final approval. The property owner shall either vacate the barn as a dwelling unit or submit a completed Use by Special Review application. For questions, I would suggest that you speak to one of our"On-Call" Planners. We have two locations open to the public. Our main office is located at 1555 North 17th Avenue, Greeley, Colorado,where we have an "on-call"planner Monday and Wednesday from 8:00 a.m.to 4:00 p.m. or Friday from 12:00 to 4:00 p.m. The Southwest Weld Office is located at 4209 County Road 24.5, Longmont, Colorado,where a planner is available every Tuesday and Thursday from 8:00 a.m. to 4:00 p.m. excluding 12:30 to 1:30. You do not need to call for an appointment as individuals are seen on a sign-in basis. To better serve you, please bring this letter with you. It is the intention of this office to assist and cooperate with you without imposing undue hardships; however, we have no discretion in this matter if you fail to correct this violation. You have 30 (thirty)days from July 8, 2003, to correct this building violation. Failure to do so will result in this office scheduling the violation before the Board of County Commissioners to consider whether to refer the violation to the County Attorney's Office for legal action. 1 _ 1 Loyd and Sheila Schlichenmayer July 8, 2003 page two Any information you have that may help to resolve this matter will be helpful. Should you have any questions regarding this letter, or if you need any further information, please feel free to contact me at the above address, telephone number or e-mail address. If you wish to see me personally, please call to schedule an appointment so that I may reserve a sufficient amount of time with you. Sincerely, Girt Arer Peggy Gregory Building Compliance Officer pc: BC-0000320 VI-0300134 Bethany Salzman, Zoning Compliance Officer Jeff Reif, Chief Building Official Bryon Horgen, Building Inspector • Weld County Planning Department GREELEY OFFICE OCS SEP 0 32003 OTIS, COAN a'Er, VIEP 19 Attorneys And Counselors At Law Fred L Otis flotis@acslaw.com • September 2, 2003 HAND DELIVER Mr. Kim Ogle Planner III Weld County Planning Department 1555 North 17th Avenue Greeley, CO 80631 RE: Loyd and Sheila Schlichenmayer VI-0300134, Part of SW4SW4 of Section 6, TIN, R68W of 6th P.M., Weld County, Colorado Dear Mr. Ogle: I received a copy of the July 8, 2003, Weld County Building Code Violation Notice to Loyd and Scheila Schlichenmayer, and an additional notice dated August 13, 2003, scheduling a meeting with the Board of County Commissioners September 9, 2003, at 10:00 a.m. First, I met with you August 6, 2003, in an effort to find a solution to the dilemma facing Mr. and Mrs. Schlichenmayer. During our meeting I believed we were attempting to resolve the issues. Mr. and Mrs. Schlichenmayer remain ready and willing to file both a building permit application and a use by special review request. Accordingly, this is to provide insight into the Schlichenmayers' personal situation and suggest a resolution which meets and complies with the Weld County Building Code and Zoning Ordinance. A little history: Mr. and Mrs. Schlichenmayer purchased the referenced property in 1998. Where the pole.barn was eventually constructed there were some unattractive corrals and outbuildings. The Schlichenmayers, as a family, operate LTS Glass in Erie, Colorado. Tammy, daughter, is the bookkeeper, and Tracy, son, (at this point) runs the business. On October 3, 1996, Loyd Schlichenmayer fell from a 16 foot scaffold. Loyd landed on his feet on concrete, stiff legged. He broke his sternum, both ankles, and a vertebra in his lower back. The channel that-holds the netve endings below the spinal cord was severely crushed. The surgery on his back took 7 hours, and the surgery on his ankles took 7 hours. The surgeon on each ankle had to remold the ankle joints from bone removed from his pelvic area. Loyd, since that time, has The Doyle Building, 1812 56th Avenue, Greeley,Colorado 80634 Telephone: 970-330-6700 Fax: 970-330-2969 Metro: 303-659-7576 September 2, 2003 Page 2 of 3 • severe chronic pain down the left leg, and only returned to work because he was one of the owners. He worked with severe pain. Finally, Loyd was unable to work. Loyd's wife, Sheila, tried to take care of Loyd, but ruptured a disc in her back from trying to carry him. Sheila spent a week in the hospital from the injury. Sheila has been diagnosed with severe osteoporosis. In early 2000 it was decided to construct an 8,000 square foot pole barn on the Schlichenmayer property. On February 18, 2000, they applied for a building permit which was granted May 19, 2000. Final inspection of the building occurred September 11, 2000. Despite, how it may appear,there was no plan to finish the barn as a residence for Tammy and Tracy until November 2000 when the family decided Sheila needed help in caring for Loyd. Coincientially, Tammy's fiance, with whom she was living at the time, died at age 35 of a massive coronary. Tammy lived 15 miles from the Schlichenmayer residence, and Tracy lived - . 10 miles from the residence. In any event, after much discussion among the family members, the Schlichenmayers decided they all needed to live in one place so they could assist each other. A plan was put in place to complete the pole barn. The attached drawing (Exhibit A) shows the approximate square footage in each portion of the pole barn. Roughly stated, Tracy's portion is approximately 1,920 square feet, and Tammy's portion is approximately 1,920 square feet, and the two areas are connected by internal doors, and a 1,280 square foot garage. The remainder of the building is committed to agriculture and storage purposes. Tammy and her son moved into Loyd and Sheila's residence in September 2001, and then moved into the pole barn residence in November 2001. Tracy and his family moved to the pole barn residence in February 2002. Both Tammy and Tracy sold their respective prior residences and committed over $300,000 to refinishing the pole barn (in addition to the initial cost of the pole barn). Each of the Schlichenmayers has expressed their regret in failing to obtain the proper permits at the time the pole barn was finished as a residence. However, the Schlichenmayers are willing to immediately apply for a Building permit and Use by Special Review permit. I am attaching a drawing(Exhibit B) of how the property has been finished, and an application for a building permit will be promptly submitted. In addition, I reviewed the Weld County Zoning Ordinance relevant to the Agricultural zone and Section 23-3-40, Subparagraph L appears to allow a use by special review for a single family dwelling unit per lot other than those permitted under Section 23-3-20A. It appears the use by special review can be restricted to a single family dwelling unit in addition to the single family dwelling allowed by right under Section 23-3-20A. Moreover, since the portion of the pole barn principally occupied by Tammy and the portion principally occupied by Tracy are connected by interior doors, and all family members are related by blood or marriage, the single family requirements have been met. All the individuals occupying the pole barn are related by blood and marriage, and have inner doors connecting the living areas. The Schlichenmayers are willing to consider other restrictions on the Use by Special Review permit which the County may impose to assure the Schlichenmayers use of the pole baru residence is not abused. September 2, 2003 Page 3 of 3 • Attached is an application for Late Registration of a Well (Exhibit C). Hopefully it will resolve the water issue. There is a separate Ieachfield and septic system that we will promptly ask the Weld County Health Department to approve it. We know of no reason why these applications will not be approved. Attached are copies of letters from Tammy and Tracy Schlichenmayer, a letter dated February 1, 2003, from Sheila Schlichenmayer to the Mayo Clinic regarding Loyd's pain and request for assistance, and other pertinent information (Exhibit D. We are unaware of any opposition from any person or neighbors regarding this matter. We will obtain letters from surrounding property owners for submission as soow.as we receive them. I implore you to consider this request from the Schlichenmayers. They have a medical condition, and significant funds have been expended to modify the pole barn into a livable residence. Sincerely, rate Fred L. Otis FLO:mas Enclosures xc: Mr. Bruce Barker eld County Attorney Ms. Peggy Gregory Building Compliance Officer Weld County Building Inspection Mr. and Mrs. Loyd Schlichenmayer OCS OTIS , COAN & STEWART, LLC a Attorneys And Counselors At Law Fred L Otis flotis@ocslaw.com September 3, 2003 HAND DELIVER Mr. Kim Ogle Planner III 'Weld County Planning Department - 1555 North 17th Avenue Greeley, CO 80631 RE: Loyd and Sheila Schlichenmayer VI-0300134, Part of SW4SW4 of Section 6, TIN, 1268W of 6th P.M., Weld County, Colorado Dear Mr. Ogle: Attached are copies of letters from the immediately surrounding property owners in support of my September 2, 2003, letter to you regarding the Schlichenmayer property: (1) Joe & Jean Baldwin, (2) Chuck& Tina Conilogue, and (3) Donald E. Iarussi, Jr. Sincerely, ee Fred L. Otis FLO:mas Enclosures xc: Mr. Bruce Barker eld County Attorney Ms. Peggy Gregory • Building Compliance Officer Weld County Building Inspection Mr. and Mrs. Loyd Schlichenmayer The Doyle Building, 1812 56th Avenue, Greeley, Colorado 80634 Telephone: 970-330-6700 Fax: 970-330-2969 Metro: 303-659-7576 ... ... . .. ............. 09/02/2003 14:04 3036657532 LTS GLASS PAGE 02 Joe and Jean Baldwin 5050 County Line Road Erie, CO 80516 September 1, 2003 To Whom It May Concern: . We are neighbors of Loyd and Sheila Schlichenmayer, their son, Tracy and his family, and Tammy and her son. We have no concerns about any of them or objections to their homes. They are kind and considerate people, have greatly improved the appearance of our neighborhood and have proven to me to be very good neighbors! Sincerely, Joe and Jean Baldwin 09/02/2003 14:04 3036657532 LTS GLASS PAGE 03 September 1, 2003 To: Weld County To Whom it May Concern: This letter is in reference to our neighbor's at 5090 Weld County Rd. 1, Erie,Co 80516, also referred to from here on out as The Sclichenmayer's. We have recently found out that The Schlichenmayer's are having problems with Weld County and their children living on the premises. We are aware that The Schlichenmayer's Children and their Families live there also, and have no dispute with them being there. The Schlichenmayer's are good neighbors and work very hard for what they have. We also feel if they were asked to move that The Schlichenmayer's would not be able to take care of the premises on there own, and if they were to move that whom ever purchased it would rent the building out as "Apartments"and we would NOT like that. We believe FAMILY COMES FIRST and that The Schlichenmayer's are doing everything-to help their Dad and Mom have a comfortable home and help maintain the premises. If you have any questions please contact us at 303-828-3048. Sincerely, judia Chuck&Tina Conilogue 5080 WCR#1 Erie,CO 80516 303-828-3048 09/02/2003 14:04 3036657532 LTS GLASS PAGE 04 Donald E. larassi,Jr. 5052 WCR 1 Erie,Colorado 80516 Home Phone (303) 828-2549 - September 2,2003 Loyd and Sheila Schlichemnayer 5090 WCR 1 Erie,Colorado 80516 RE: Questions regarding family living in separate quarters on property at 5090 WCR 1,Erie,Colorado. To Whom It May Concern: In regards to the property located at 5090 WCR 1,Erie,Colorado 80516. We,the owners of the prop..ty at 5052 WCR 1,Erie,Colorado 80516,have no concerns or reason to feel that the owners of the property at 5090 WCR 1,Erie, Colorado are in any way a burden on the fellow neighbors or that they are creating a negative visual impact. It is our feeling that they have plenty of area surrounding the property and are neighbors who support positive values(IE— Family values,Proper care for property,Property improvements, Respect of fellow Neighbors,etc.). Our small community of homes with a common,private exit onto WCR 1 is by no means overbuilt or overcrowded. With regard to keeping the family together and allowing the residence to continue to exist as is,we are writing this letter in support of their arrangement Our families have come to know Loyd and Sheila Schiichenmayer,Tracy Schlichenmayer and he,family and Tammy Schlichenmayer and her son. It is our hope that this matter can be resolved quickly and simply for all concerned and that the city/county will grant the necessary permit to allow all to continue living as they have been on the property at 5090 WCR 1, Please feel free to call if any questions or comments need clarification. We are happy to help, •m• Jy// Id E.larussi,Jr. FAMILY IS THE WORLD TO US. NOT ONLY DO WE WANT TO LIVE TOGETHER AS A FAMILY, WE OWN AND OPERATE A FAMILY BUSINESS TOGETHER. AFTER DADS ACCIDENT, WE DIDN'T THINK HE WOULD EVER WALK AGAIN, - LET ALONE WORK AGAIN. WHEN HE WAS ABLE TO WALK AND EVENTUALLY RETURN TO WORK, WE WERE ALL VERY RELIEVED. HOWEVER AS TIME WENT ON, IT WAS VERY OBVIOUS THAT HE COULD NOT CONTINUE ON WORKING. IT WAS, AND STILL IS, VERY PAINFUL TO WATCH YOUR OWN FATHER GO DOWN HILL. HE COULD NO LONGER HELP MOM LIKE HE COULD BEFORE. DURING ALL OF THIS, MOM TOOK ON ALL THE EXTRAS INCLUDING HELPING DAD AND ENDED UP IN THE HOSPITAL WITH A RUPTURED DISC. SHE WAS LATER DIAGNOSED WITH OSTEOPOROSIS. I LIVED 15 MILES AWAY AND TRACY LIVED 10 MILES AWAY. WE WERE MAKING LOTS OF TRIPS TO HELP AS MUCH AS WE COULD. SINCE OUR FOLKS HAD ALREADY HAD THE BUILDING PUT UP FOR - . SOMETHING ELSE, WE ALL DECIDED IT WOULD HELP EVERYONE IF WE MADE IT LIVABLE SPACE. ALTHOUGH WE KNOW IT WASN'T THE RIGHT WAY TO DO IT, IT WAS THE BEST WAY TO HELP OUR PARENTS AND OURSELVES. DURING CONSTRUCTION, MY FIANCÉ WHO WAS THE PLUMBER AND HAD COMPLETED THE UNDERGROUND, PASSED AWAY. HE WAS ONLY 35 AND HAD A MASSIVE CORONARY. IT GOT HARDER NOT ONLY EMOTIONALLY, BUT ALSO FINANCIALLY. MY FAMILY HELPED ME SELL MY HOUSE AND MOVED MY YOUNG SON AND I IN WITH MY PARENTS UNTIL CONSTRUCTION WAS FINISHED. AFTER ALL OF THIS, WE REALLY WANTED TO BE THERE FOR EVERYONE AS A FAMILY. TRACY AND HIS FAMILY LATER SOLD THEIR HOME AND WILLINGLY MOVED THERE. IT HAS BEEN A GOD SEND TO LIVE THERE. NOT ONLY CAN WE ALL BE THERE TO TAKE CARE OF THINGS, BUT OUR 20 YEAR BUSINESS HAS HAD SOME FINANCIAL TROUBLE THIS LAST YEAR. WE WERE ABLE TO KEEP IT GOING BY NOT TAKING PAYCHECKS BECAUSE WE DIDN'T HAVE HOUSE PAYMENTS. THINGS ARE COMING AROUND BUT IT HAS BEEN VERY DIFFICULT. THE BOTTOM LINE IS, WE LOVE OUR FAMILY AND IT WOULD NOT ONLY BE EMOTIONALLY DEVASTATING BUT ALSO FINANCIALLY DEVASTATING TO HAVE TO LEAVE. OUR PARENTS HAVE DONE MORE THAN YOU COULD, IMAGINE FOR US. NOW IT IS OUR TURN TO DO FOR THEM. TAMMY SCHLICHENMAYER TRACY SCHLICHENMAYER EXHIBIT D FEBRUARY 1, 2003 MAYO CLINIC CHRONIC PAIN DIVISION ROCHESTER, MN 55905 DEAR CHRONIC PAIN DIVISION, I AM WRITING AS A LAST RESORT FOR MY HUSBANDS' PAIN. IN 1996 AT THE AGE OF 58, HE FELL 16' FROM A SCAFFOLD. HE LANDED ON HIS FEET, STIFF LEGGED, ON CONCRETE. THIS SHATTERED BOTH ANKLES, BROKE HIS STERNUM AND BROKE A VERTEBRA IN HIS LOWER BACK. ALSO THE CHANNEL WHERE THE NERVES RUN BELOW THE SPINAL CORD WAS FLATTENED. THIS IS WHERE THE PROBLEM IS. THE SCIATICA NERVE FROM THE CHEEK OF HIS LEFT BUTTOX DOWN THROUGH THE FOOT. WE HAVE TRIED EVERYTHING FROM ACUPUNCTURE TO HYPNOSIS AND BEYOND. RIGHT NOW HE HAS A PAIN PUMP WHICH HAS GOTTEN HIM OFF ORAL MEDICATION BUT THAT IS ALL. HE STILL HAS SO MUCH PAIN IT'S HARD FOR HIM TO FUNCTION. HE RECEIVES 13 MILLIGRAMS OF MORPHINE PER DAY THROUGH THE PUMP. TO KEEP RAISING THE DOSAGE COULD RESULT IN THE CRYSTALLIZATION AT THE END OF THE CATHETER. WE EVEN ASKED ABOUT CLIPPING THE NERVE, BUT WERE TOLD HE WOULD DRAG HIS LEG AND PROBABLY HAVE PHANTOM PAINS WHICH ARE TWICE AS BAD AS THE PAIN HE HAS NOW. WE WERE TOLD SOME PEOPLE HAVE COMMITTED SUICIDE FROM THESE PHANTOM PAINS. WE ARE AT OUR WITS END. WE HAVE KAISER INSURANCE WHICH HAS PAID GREAT, BUT WE ARE AT A PLACE WHERE WE DON'T KNOW WHERE TO TURN. COULD THERE BE ANYONE, ANYWHERE THAT MIGHT BE ABLE TO HELP US ?? I HAVE NOT APPROACHED OUR INSURANCE UNTIL I KNOW SOMETHING. WE WOULD APPRECIATE ANY INFORMATION YOU COULD GIVE US. SINCERELY, • SHEILA SCHLICHENMAYER HUSBAND: LOYD SCHLICHENMAYER 5090 WCR#1 ERIE, CO 80516 PHONE: 303-828-3013 Pre-Interview Fact Sheet Please answer the following questions as completely as possible. This form will assist us in the completion of your claim. Bring this form with•you to the interview or have readily available for your telephone interview. Proof of this information may be required. Your Name: „ ayS 2pt ' kcr,b J r c hP n malt!' SSN: 64y— 4 1116 MaHing Address: SO 90 (Ai C 4, 1 City: f'i P State: co Zip Code: 70.57 4. Telephone: ('as 7447-24047 Date of Birth: /C-/(y Place of Birth j(JJ-.Jj!lapin (AO ***************AA AAA kk*****************************************************#* Do you have an Original or Certified Birth Certificate? es No (circle) Dates of Active Military She�C�/ 4 C1 sr_J A q , Are you currently working?: Yes - No (circle) Employer's Name:a• G . Employer's Address: 2700 S. in FYI c 7- F`y`it L1 ice S p •Earnings for last year: Wages $ Self-Employment$ Current year earnings: Wages $ Self-Employment Do you have any Biological or Adopted-children? es No (circle) Please list any children age 19 or younger or any disabled adult children: NAME. Date of birth SSN NUN & — • *****qtr*************************************************************et*******rte Have you ever worked for the City, State, or Federal Government? . Yes o (circle) Are you disabled? es No (circle) If Yes, when did you become disabled or unable to work because of your disability? (OVER) air PLEASE COMPLETE THIS QUESTIONNAIRE BEFORE YOUR INTERVIEW YOUR NAIVIE: ✓ , SeJ 114' yer YOUR SSN: 5-49/ //S ADDRESS: s'C '> WC / PHONE #: (3 ay) a�3O% Ertl t CO to S/ o DOB: J o- l fi- a? DO YOU HAVE A BIRTH CERTIFICATE? Cg9 NO YOUR CURRENT OR LAST MARRIAGE TO WHOM MARRIED: S h e.J j a- SCh l 1 c r!@Y1 rn ayeir WHEN: 7-;11- G D ci30 der- • HOW MARRIAGE ENDED: WHEN: n/ / - WHERE: G / SPOUSE'S DATE OF BIRTH: 4/-/C-5 9' IF SPOUSE DEACEASED_DATE: N14 • SPOUSE'S SSN: sale- 4(,-334 2 PRIOR MARRIAGE ro-WHOM MARRIED: WHEN(month, day, year): 6 4 4- WHERE: • IOW MARRIAGE ENDED: iick VEEN: MERE: ROUSE'S DATE OF BIRTH: SPOUSE DEACEASED-DATE: Ifr ?OUSE'S SSN: :EASE LIST ADDITIONAL MARRIAGES ON A SEPARATE SKEET OF PAPER, ALSO,IF YOU ARE FILING FOR IDOW(erpS OR DIVORCED SPOUSE'S BENEFITS, COMPLETE THE SAME MARRIAGE INFOIiMATION AS QUESTED ABOVE REGARDING YOUR SPOUSE'S PRIOR MARRIAGES. DO THIS ON A SPEARATE SHEET ?PAPER D OU HAVE ANY CHILDREN UNDER 19? If yes, list their names, dates of birth and SSN: MMES: DOB: SSN: ARE QUESTIONS ON BACK Form Approved SOCIAL SECURITY ADMINISTRATION • OM Na 08E0-O579 • For SSA Use Only DISABILITY REPORT • Do not write in this box. ADULT Related SSN fi Number Holder 2. SECTION 1- INFORMATION ABOUT THE DISABLED PERSON I A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER iX D. C. OAYTIME TELEPHONE NUMBER (lf you have no number where you can be reached, give us a daytime number where we can leave a message for you.) a 3�. Mir- r Cods Number Your Number El Message.Number ElNone D. Give the name of a friend or relative that we can contact (other than your doctors) who ir knows about your illnesses, injuries or conditions and can help m J . cc a p you with your claim NAME Fracy J. S0.11 I i r,�N.y) rn aye r RELATIONSHIP Sly < w m xi , s ADDRESS s CC1C LO OE ) 4o N I(Number, Street,Apt, No.Bf any),P.O. Box,or Rural Route) D El-4 1^I e._ `/3 �Q S/� DAYTIME a City Stare 3d 3 �! 1-�3 ?f 3 ZIP PHONE Area Code Number T O E. What is your F. What is your weight • height without — 1—_ without shoes? V-) n shoes? eat . ia G. Do you have a medical assistance card? (For Example, Medicaid rn 2 p n YES NO or Medi-Cal) If "YES," show the number here: �° W `a H. Can you speak English? 1YES n No If "NO," what languages I. 3 can you speak? I • If you cannot speak English, is there someone we may contact who speaks English and will give you messages? (If this is the same person as in D"above show "SAME"here.) NAME RELATIONSHIP `; ADDRESS F, S (Num ,Street,Apt. No.df any), P.O. Box,or Rural Route) Y' • .t DAYTIME City State ZIP PHONE Area Code Number x. I. Can you read English? BYES ❑ NO J. Can you write more than i[YES n NO your name in English? s. SSA-3368-BK (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 1 • SECTION 2 YOUR ILLNESSES, INJURIES OR CONDITIONS AND HOW THEY AFFECT YOU A. What are the illnesses, injuries or conditions that limit your ability to work? Moto,/ 14 both a'n l e.s -meal JOlvtrr✓ac J-- 4- Se—ay—re chnnhh. k2oin '%m N1ervt ei-CUn j n ha_G How do your illnesses, injuries or cefiditions limit your ability to work? 11&r't-L —1'© Wad k mop c r- A e4i u vl ahl e to /1' f- �-- OA rat;cn Seleala my etur/i bri u.)n• C. Do your illnesses, injuries or conditions cause you pain ig YES ❑ NO • or other symptoms? D. When did your illnesses, injuries or Month Dffivea conditions first bother you? /0 J #� E. When did you become unable to work because Moth Day Year of your illnesses, injuries or conditions? T. F. Have you ever worked? NT YES ❑ NO (If "NO,"go to Section 4.) G. Did you work at any time after the date your illnesses, injuries or conditions first bothered you? E YEs ❑ No H. If "YES," did your illnesses, injuries or conditions cause you to: (check all that apply) yjs work fewer hours? (Explain below) g. change your job duties? (Explain below) Eir make any job-related changes such as your attendance, help needed, or employers? (Explain below) cwt`- hew-6 wore al- Cl1d 1,,hi-werfht akep work cold net ,r.phcenj7,01 -t-® 442blue print u)oi-k. 1,UarKod, mV CLOY? kdttws I. Are you working now? O YES ' bij NO If "NO," when did you stop working? Month Day year D2.— J. Why did you stop working? ? ;y) b&-tame, �jp s o_s)nc FORM SSA-3368-8K (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE: SECTION 3 - INFORMATION ABOUT YOUR WORK A. List the kinds of jobs that you have had in the last 15 years that you worked. ..-....' a r > t It g."ya IBS i'i?N,.ti+ f i' �i.6i 3Ka ''n rj'�fiY i-}w.li s 1:1ij n'i 1 iw��L y s { .. yy .mow g ie�v� i i �.'_ ,' RtDAFS RATS OF PAY �iYW0llflt 3 ,A f " ict i ,So"r/bIP �i: Glaze" 4-(cit r Glass Shop. 10-5411-02-- , /2 $ va1'i� ( $ $ $ $ $ B. Which job did you do the longest? own h1i.5ipm SS S47,e /9/9/r-b �9)vim C. Describe this job. What did you do all day? (If you need more space, write in the "Remarks" section.) N-- �� ✓�)a� KP.ccei b 11.G PY-i koLT 4- c1 I X77 kg_ O-Ms. D. In this job !!��, did you: Use machines, tools or equipment? 0-YES ❑ NO Use technical knowledge or skills? ET YES ❑ NO Do any writing, complete reports, or perform duties like this? K YES *'NO E. In this job, how many total hours each day did you: Walk? _ Stoop? (Bend down&forward at waist.) Handle, grab or grasp big objects? _ Stand? Kneel? (bend legs to rest on knees.) Reach? Sit? Crouch? (Bend legs&beck down&forward.) Write, type or handle small objects? Climb? Crawl? (Mow on bends& knees.) F. Lifting ryi g (E /lain what ou lifted, how far ou carried d, and how often you-did this.) aks55 .fir shO(var CLOP,5 - spm,o WPM earth 'i 5 Oar etc azao s d Zs ever!/ d/ G. Check heaviest weight lifted: O Less than 10 lbs ❑ 10 lbs ❑ 20 lbs ❑ 50 lbs 100 lbs. or more O Other • H. Check weight frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the wot'kday.) O Less than 10 lbs ❑ 10 lbs O 25 lbs 50 lbs. or more O Other I. Did you supervise other people in this job? OSJ YES (Complete items below.) O NO (Skip to next page.) How many people did you supervise? What part of your time was spent supervising people? -30 `4 Did you hire and fire employees? trisiYES ❑ NO J. Were you a lead worker? YES ❑ NO 0RM SSA-3368-8K (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 3 SECTION 4 - INFORMATION ABOUT YOUR MEDICAL RECORDS A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions that limit your ability to work? Lt YEs ❑ NO B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems that limit your ability to work? O YES tg NO If you answered "NO" to both of these questions, go to Section 5, C. List other names you have used on your medical records. Tell us who may have medical records or other information about your illnesses, injuries or conditions. • a List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment. 1. NAME V. 1 s,k Ir,11h` t:`;,;40,13:: .D r. 31-pr n [tea v l i k :` STREET ADDRESS 933 jq ' i ne.- C�/ISiT cm'', ST ZIP LAST SEEN �Q u.IcWr V 10309 PHONE 03 414912 7 3 n CHART/HMO S (If known) NEXT APPOINTMENT Ana Code Phone Number /11((ff REASONS FOR VISITS 6.-/j Ave/ stai4id- Dr;Nit/ remcldta[. bid? owl?Ye, nfs. rn Sept anon Dr iiuJ had * sc +ht Le 1- p*ik I o i-0 pain, WHAT TREATMENT WAS REtEIVED? j x 4insive- surd/ i� Yv both s'.hfl/.S v 2. NAME ( ' ' q 7',{w i w '+ii.R•T •- s DrW ) I l a m (N d I J1 can S � . �£ STREET ADDRESS 3 ;vi FIRST VIS T 10 -9� CITY R� I �trAT� ZIP p03O//• LAST SEEN PHONE 103 im �u7 2O C�CCHART/HMO S 0f`known) . NEXT APPOINTMENT a.,.Code MVOS Numbed re REASONS FOR VISITS /l -�yAm src 41t- Dr to llipyns rep re brokor ✓erte-brcl✓ ; n back- repaired- newt darn ' 2 cannel WHAT TREATMENT WAS RECEIVED? � �( f p{ '//ei 5 tt /Older keze-k f�lc� sr,d betel< s rf ut^ aka 1-r) bral��-, i,n3 vfl I Yl & 'ccj i ) t -Teddy - i YISertti &g 1 / ii m u..lect0 ` �noe. SAA_31RR_RK 111_91 (11% Pc 111_9nf11 TA. ooa .datinn na., h.,,.ml ,,n.;i .,,,,.,,.,va oar_ SECTION 4-INFORMATION ABOUT YOUR MEDICAL RECORDS DOCTOR/HMO/THERAPIST/OTHER 3.NAME a 'SyF'�'�wt ,w 'F4'S{ i � ,S} � n;,Wr Dr. rs erta fa+�.�'tft & i'i,,, STREET ADDRESS t 37S rh it FIRST VISIT/ 97 9 CITY 11V�Y, ST ZIP LAST SEEN 4/fl �O�o5 No sure PHONE :gal grit. 3,2/O CHART/HMO # (If known) NEXT APPOINTAM' NT Anew Cade Phone Number ,Y f i REASONS FOR VISITS &pi thittil Shp w- a CCLep(Zf7t r{d WHAT TREATMENT WAS RECEIVED? • Set, (fgj)/p� If you need more space, use Remarks, Section 9. E. List each HOSPITAL/CLINIC. Include your next appointment. u , C i its•, 'Yy a u, 1 Mw »dhi! ,x,}test r P q. S ,��}4�� ilti `c /*1 tt�r ::kill ll VFW' nx 5 . ' ' �4.4 � r i?`f+�� '. - {S Sn a?l i ".� n. • i. a_ „�4''.>Ga� � i NAME � INPATIENT Bo Oder Col STAYS / —3-9Co mid © ill/?// y (Stayed at least y a i cQ 9-3a-00 STREET/ ADDRESS / overnight) 7 -11 /jag Ea/5 CM � OUTPATIENT 6: I` ' ' itLL CITY STATE ZIP VISITS , &��`, l �/ CO p �1 (Sent home same uldtr C OQ3O-7 day) y gyp p PHONE EMERGENCY o3 41/40-8273 ROOM VISITS 10- 3- 3G Am Cad, Fhone M,m,eo Next appointment &s l J? Your hospital/clinic number 303_L [/ -27,10 Reasons for visits 0 h a`v Up What treatment did you receive? vi- / x rays 7 7 kt S Lett. Prof //#S tart LUdrKi'nf What doctors do you see at this hospital/clinic on a regular.basis? Dr, ?ad Pr W;lldc ns FORM SSA-3368-BK (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 5 SECTION 4-INFORMATION ABOUT YOUR MEDICAL RECORDS HOSPITAL/CLINIC 2- ; Hta'1SPtt�AUC!ll iG NAME INPATIENT '4 raar at -0 F 1:n St. T0S1Oti5" ,sr S STT at/east STREET ADDRESS overnight) ins Fr AI// OUTPATIENT ' 3 ; NAINIt r • CITY STATE ZIP VISITS (sent home same n�A n a eroair PHONE EMERGENCY kl , _ _ • c" r eta:"max`` 3 03 137-1/// ROOM VISITS M..Cale �h.a. mrk. Next appointment Al 1)4 Your hospital/clinic number Reasons for visits Cjj}{ u to What treatment did you receive? What doctors do you see at this hospital/clinic on a regular basis? r% pbpi5 If you need more space, use Remarks, Section 9. F. Does anyone else have medical records or information about your illnesses, injuries or conditions (Workers' Compensation, insurance companies, prisons, attorneys, welfare), or are you scheduled to see anyone else? ❑ YES (If "YES, " complete information below.) • D3rNO NAME oi;o 4,,r.: aSS3 5F'Sji bb »#A.:^giiiii iS.i1bk0 STREET ADRESS FIRST VISIT CITY - STATE ZIP LAST SEEN PHONE NEXT APPOINTMENT A,..Code Mane Number CLAIM NUMBER (If any) REASONS FOR_VISITS If you need more space, use Remarks, Section 9. FORM SSA-3368-BK (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE SECTION r5 - MEDICATIONS Do you currently take any medications for your illnesses, injuries or conditions? 18] YES If "YES," please tell us the following: (Look at your medicine bottles, if necessary.) 0 NO ;t1 k!,4*. z /910/04 ill& 7r Penh an? Faj n _ fir ss If you need more space, use Remarks, Section 9. SECTION 6 - TESTS Have you had, or will you have, any medical tests for illnesses, injuries or conditions? O YES NO If "YES," please tell us the following: (Give approximate dates, if necessary.) •z � i�cyy Y h l iX ₹ ' 1 1 11411• tit •.Y' �y L it t f xs �, s " �4 " 5�'s 'W dt H'N' s u � A t: �? v� �t� a'7 tm " " r N b a'Rit�A. 1ui 1; �.lt �. rr4 KAP. !d 4 � r i F ,3 5� t"^;:}ir ,.uw•g11T i�t g �a < asl v4{� i{ .' 1. 4 # xFttB' s; tii +ex. sky +2.: wt _ m ;, „L .dY,:y{'k#•wA ym t .�y � 3. ,`,y,�@ + 'tti' aq f �Yy s BIOPSY—Name of body part 11 LEG teMihl WAVE T — }UV'REST .1041 .. S $u X-RAY—Name of body part MRI/CT SCAN Name of body part If you have had other tests, list them in Remarks, Section 9. FORM SSA-3368-8K (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 7 • i a SECTION 7-EDUCATION/TRAINING INFORMATION heck the highest grade of school completed. de school: College: 1 2 3 4 5 6 .7 8 9 TO 11 12 GED 1 2 3 4 or more ❑ ❑ ❑ ❑ ❑ ❑ ❑ D' ❑ ❑ ❑ ❑ ❑ ❑ -❑ ❑ ❑ iroximate date completed: /96/ )id you attend special education classes? ❑ YES 'NO (if WO,"go to part C) I NAME OF SCHOOL • ADDRESS • (Number, Street, Apt. No.(if any), P.O. Box or Rural Route) { City State Zip DATES ATTENDED • TO TYPE OF PROGRAM lave you completed any type of special job training, trade or vocational school? ] YES c5d1,40 If "YES," what type? Approximate date completed: SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, or OTHER SUPPORT SERVICES INFORMATION you participating in the Ticket Program or another program of vocational rehabilitation 'ices, employment services or other support services to help you go to work? YES (Complete the information below) Igt NO NAME OF ORGANIZATION NAME OF COUNSELOR ADDRESS (Number, Street, Apt. No.(if any), P.O. Box or Rural Route) City State Tip E; DAYTIME PHONE NUMBER Area Code Number �t DATES SEEN TO • TYPE OF SERVICES OR TESTS PERFORMED (/O, vision, physicals, hearing, workshops, etc.) SSA-3368-BK (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 8 SECTION 9, - REMARKS 9r. 4bra ms -2093 Frar10/7 Sit Volved6©. elS,2os 203- 2-00/- 3303 - /lead ca/7on was net clntivl[in n serfad Ing h-oni c ja i'h Plant So rOarizt cider- 10309 3 1 - 113(9rb0 - cnntrnjs c gs mtd ec i'dh iv) f eu n cikn • - PSa ola rharph/'n t Tiicii S t RouJdei- Mann rs Baseline apcider- co ioSa3 302. -494 - 0636- rtarnm,d 6cf 9b Td .Cast ,at 96 I.as in Rc'ecldu- rnuwr 4yr ` % 6 Anse ha tit gm/ le ec& //needed - set aylac e NYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL FACT DR USE IN DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL SECURITY ACT OMMITS A CRIME PUNISHABLE UNDER FEDERAL LAW. gnature of claimant or person filing on claimant's behalf /parent, guardsn) Date (Month, day, year) 4/ itnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (XL 'o witnesses to the signing who know the person making the statement must sign below, giving their II addresses. Signature of Witness 2. Signature of Witness , ddress (Number and street,city,state,and ZIP code) Address (Number and street,city,state,and ZIP code) M SSA-3368-8K (11-2001) EF (11-2001) The 12-1998 edition may be used until exhausted PAGE 10 MB No. 098SOCJAL SECURITY ADMINISTRATION O Approved 096 OMB 0-0598 WORK ACTIVITY REPORT (Self-Employed Person) • Name of disabled ppersoqn Blind Social Security Number ail!i C he-Jingler ler • Not Blind LOYD L. .,...1-.Z. rzar. 524-48-117.5 Name of W/E (If other than disabled person) Social Security Number PAPERWORK)PRIVACY ACT NOTICE The information requested on this form is authorized by Section 223 and Section 1632 of the Social Security Act. The informaiton provided will be used in making a decision on your.claim. While completion of this farm is voluntary, failure to provide all or part of the requested information could prevent an accurate and timely decision on your claim and could result in the loss of benefits. Information you furnish on this form may be disclosed by the Social Security Administration to another person or governmental agency only with respect to Social Security programs and to comply with Federal law requiring the exchange of information between Social Security and another agency. We may also use the information you glue us when we match records by computer. Matching programs compare our records with those of other Federal,State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government.- The law allows us to do this even if you do not agree to it. Explanations about these and other reasons wny intormanen you provide us may be used or given out are available In Social Security Offices, It you want to learn more about this,contact any Social Security Office. PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C. 53507, as amended by Section 2 of the Paperwork - Reduction Act cf 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 30 minutes to read the instructions,gather the necessary facts,and answer the questions. Please use this form to describe your work activity since (Date disability 1 . Date Ito be entered by SSA) began or, if later, date of prior investigation) 01-01-2000 ANSWER EACH QUESTION AS FULLY AS POSSIBLE A. List name and address of business (include zip code) Lrs G-JaSS v- f-Eamt rrpprav&mem'.L"h c 2. 'tr'o't S•Co ALi P ST' B. Please Check if C. Briefly indicate the primar(y product or service ❑ Farm u4 Non-Farm Fuji servit.e 2I&ss ova, LP X to L?5� diVJ _ A. Describe the business in terms of arrangement and /or ow, ership (Check one CD r . J\ fl Sole Owner 0 Partnership n' Farm Tenant n Farm Landlord B. Give your monthly self-employment income since the above date (average if not sure) Month' Year Gross Net Month; Year Goss Net Month; Year ;Gross Net 3, at 6,-. As &.1 the eetr-011 Osj, _ Month: War Gross Net Mon Year Gr s Net Month Year Gross Net • • C. List any months in which you earned more than �l-Qyf/ a- yao uJcYt p LiztGK c 6. $200.00 or worked more than 4O hours in your air Q�// d./.1 not business since the date shown in item 1. , l� •C L/ /7 mom 11fr ./it/ c A. Describe (briefly) what you did in the business in terms of management ecisions, responsibilities, hours, production and..services before your illness or injury. ,Wee., aid at &phi/uis "es- 2/ )1VG Qor/e, — did adi t it&yt,'h 7" ,zl!t- • 4 dilltim fes. D i g w>"s)'d tfY/eat yr--- i 125 i de_ shop work. B. Was this business your sole livelihood prior to your illness or injury? YES 0 NO Please describe your present work activities and any changes in your business because of.your illhess or injury. Explain such things as reduced hours of business, lower volume, fewer acres under cultivation or other.eQ (If you use extra help, write "extra help" here and provide the details when you get to item 9}, m .�77 prtS¢,rt , 2 was IAA a-bIg. -tD cop S- with �-}, et pcza,7 ubcse Oi - 5. neled,ca.7ionS wo ELVi.a-blt 11, &PP60141^a7te-. ill/ h0it '5 _hp_r_cymA Do,(did) you make management decisions after your illness or injury? YES NO (If "yes," describe the kinds of decisions made, the time spent making them and any gin that have taken place).skl -Hit vnarn �QS ._ ,y0t tg Sta.rtIg i on 6. t nm Jobs . �1pin t± mtes 1; s f-a.yed cavil !e- lowf' titS (4, wtint back kwmp . • A. If you began your business after you were injured or became ill, did you receive any special assistance from an agency or other source in setting up your business? YES ® NO B. Does this assistance continue or have additional special services been supplied? O YES ET NO 7, (If "yes," please describe) • A. What is the value of any normal business expense which you do (did) not pay including that which is furnished or paid for by another person or organization (such as free space or utilities)? Why were such items supplied to you for free and by whom were they furnished? 14PC • 3 B. Describe any special expenses related to your illness or injury that you paid which are necessary for you to work (for example, attendant care, medical devices, equipment, prostheses, or similar items or services). • • DESCRIBE ANY ADDITIONAL HELP YOU NEED(NEEDED) IN PERFORMING YOUR USUAL DUTIES BECAUSE OF YOUR ILLNESS OR INJURY. A. Number of assistants B. Time they devot d to helping you C. What do (did) theystt �} 'nil(tine a Worr G_o-r� rhr .l�J� ' D. Areiwere assistants check one) E. If paid, how much? neNd�_ p i- tnt ,J PAID UNPAID ,iP - down 7 with�, , F. Is (are) assistant(s) r; -d to yo 7 heckone) G. If yes, wh t is the re,J�tio • u het Chap^ Y—o a'e e-_ IO YES NO Sfzn �" W1-Pt. H. Why was the additional help needed7�- fojj gt kn-1.4, 1 pink Its o- aJtZ5 tim /€ 5�v Walk hiAtier m y .mss earn a z/ r had an e/h-i'c s cater the ,24 me with• i mice hod ticwl2ctr o blzc4< Lora-ct • J'4 • • • • rrn SSA-824-F4 (2-1991) EF (12-2001) 2 If you need more space for any answer, use Page 3. think will be helpful. Please refer to the previous questions by number, such as 4A or 46 or 5. • • 10. • If more space is needed, use an extra sheet. A. Check the appropriate block below: Xi I am not receiving Social Security disability benefits and/or supplemental security income (SS1) 1 1 • n I am receivingSocial Security disability benefits and/or supplemental security income (SSI) and f understand that the information provided above may result in my benefits being stopped. I have been given the opportunity to submit any evidence I wanted and to make any statements concerning my claim. PLEASE READ THE FOLLOWING STATEMENT, THEN SIGN, DATE AND PROVIDE ADDRESS AND TELEPHONE NUMBER. Knowing that anyone who makes a false statement or misrepresentation of a material fact for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law, I affirm that the answers to questions on this form are true. Sig ature of claimant/b eficiary or representative Date Zs° .eo -rti��„t...�-c 7- /o -042- Mail' g address WC- and Street, Apt. no., P. Box, or Rural Route.) TELEPHONE (Include area 50 9'0 W C R code) 303— spat 3019 City _ State County Zip Code EV% 1 LD LUe- d_ 8aS/� Form SSA-820-F4 (2-1991) EF (12-2001) 3 • • • Bolder Community Hospital Sadder, Colorado 80007 • - and_ } a-Uf su cry SCHLICBMINNYER, LOYD 25001231 26-93-47 ADS: 07/09/97 Room #: 2212 DIS: DOB: 10/16/38 084; 524-48-1115 CARRIER #1: KAISER INPATIENT POLICY #: 004481115 (3RD #: 375301710 DATE OF OPERATION: 07/09/97 SURGEON: WILLI M a. WILLIAMS, ND ASSISTANT: STEPBSN PAUL, MD ANESTHESIA: General endotracheal/TH01188 CBALpg, ED PREOPERATIVE DIAGNOSIS(E3 : Left sciatica, left L4 and L5 radiculopathy, pseudarthrosis, L3-L5 fusion. PCSTOPERATIVE DIAGNOSIS(ES) : Left sciatica, left L4 and L5 . radiculopathy, pseudarthroeis, L3-L5 fusion. OPERATIVE PROCEDURE: PARTIAL CORPECro criLacranr L4 ON THE LEFT; D , 11TTB POSTERIOR LUMBAR IHTERBODY FUSION L4-5; TAKE-DOWN PSEUDARTfROsIS 11ITH RE-DO POBTEROLATERAL =SICK L3-4 AND L4-5 WITH ELECTRICAL STIAea,ATO$ AND LEFT n.r.r BONE GRAFT. INDICATIONS: The patient is a 56-year-old gentleman who fell 20 feet from a scaffolding onto concrete on October 3, 1996, sustaining a severe L4 burst fracture occluding the spinal canal, in addition to bilateral pilon fractures of the ankles. He bad a posterior spinal reduction and fusion at L3-L5 with mild residual cauda equine syndrome. He had weakness of the foot and ankle dorsiflexors on the left side from the start, but in the last four months be has had worsening of the left sciatic pain, primarily at L4 and 16 darmatomse. Ankle and toe dorsiflmden remained weak on the left side. His special studies showed bons fragments near the L4-5 foramina as well as scam bulging of the L4-5 disc on the left side. Pseudarthrosis was suspected due to thready bone formation and on the recent flexion and extension film, fracture of the left L5 pedicle screw. Repeat surgery was elected. DESCRIPTION OF OPERATION: Under adequate general endotracheal anesthesia, the patient was turned prone on the Andrews spinal table. All bony prominences were padded. Shoulders and elbows were flexed less than 90 degrees. Preoperative Ancef was given. A Foley catheter was placed and spinal cord monitoring using HMO potential was utilized. The lumbar region was prepped and draped in sterile fashion using an Saban adhesive drape over the akin. His previous incision, 6 inches in length, was opened. The subcutaneous layer was sharply divided. Bleeding was controlled with electrocautery. The deep fascia was divided with the electrocautery knife and the spinous process of 13 outlined above and L5 below. The lumbodorsal fascia and muscles were elevated subperiosteally out over the previous lam nectomy and fusion site as well as out over the spire process and lamina of L3 above and LS below. The transverse connector was then identified and removed. The Isola rod was removed from the left side as well as the interpedicular slotted [erectors. The fracture screw at L5 on the left was removed. The screw above and the O)ININTIVE RIMOk4T Page 1 of 3 Copy for DAVID HAUYaWSS, MD, Boulder raiser Permanents • • • • Booley Ca =IlatY 1�ospidl Bandar, Colorado 80001 BCBLICBANNATER, LOYD 25001231 26-93-47 ADl(: 07/09/97 - Loom 4: 2212 DIS: screws on the right side appeared stable and were left alone. He had a dense, fibrous union of his bone graft in both lateral gutters. Interestingly, the original cancellous bone had turned to dense scar rather than bone. Pseudarthrosis was apparent primarily at L4-5 but also at L3-4. The posterolatsral fibrous tissue was removed with rongeurs. The transverse processes L3-L5 were freshened with the Aumpach bilaterally for re-do of hie pusterolateral fusion. Next the transverse process was followed to the pedicle of L4 on the left, and using rongeurs and the high-speed bur, the pedicle of L4 was raved. There appeared to be significant pressure on the left L4 nerve root between the pedicle and a wall of bone. There was also some preesurs from the L4-5 disc pushing up on L4 from below. A complete pediculectcm<y was done. There was still soma prominence of retropulsed bone from his L4 burst fracture. The nerve root and dune were retracted medially and then the high- speed bur used to do a limited corpectomy of the upper left side body of L4, removing prominent bone so that the L4 and L5 nerve roots would have a flat bed in which to rest. epidural bleeders were controlled with the bipolar cautery. The foramina was opened with Harrison rongeurs all the way laterally more than 1 c lateral to the extant of the pedicle. Neat, the L5 nerve root was tracked distally. The pedicle screw was not impinging on the nerve root. Impingement of L5 appeared to be at the L4 body. We could pass a 4-mm gallbladder probe out along with the b£a nerve root as well as along L4 and L3 once the decompression was completed. Next, a diskectomy at L4-5 was done. The end plates were decorticated using ring and angled curets as well as the AcrcKed 10-mm and then 11-mm PLIG cutters. Disc fragments were removed with pituitary rongeurs. Attention was then directed to harvesting the bone graft. The same skin incision and a separate fascial and skin incision was utilized over the left posterior-superior iliac crest. The cautery knife was used to divide the soft tissues. Then the gluteal muscle attachments were elevated subperiosteally from the posterior crest. We harvested two 11-see width, 5-mm blocks of half the width of the iliac crest to use for structural grafts and then abundant corticocancellous bone from the posterior ilium. The wound was irrigated with antibiotic irrigation. Salfcam was placed. A suction drain was placed, and the wound was closed with a running 1-Vicryl suture. The bone graft was packed into the inner space, and fiat cancellous, and then the structural grafts, placing them flat and then rotating to distract to the disc space place anteriorly. The remaining specs was filled with bone. The bone graft appeared to be very stable and was flushed posteriorly without nerve root impingement: Next, the pedicle screw was placed at L4 on the left. We opted not to place. • the screw at L4 on the right. The screw was redone at L5 on the left as the retained portion of screw appeared to. pose no problem and would have been very difficult to remove. The new screw was first placed above, but this did not have good purchase, so a new 5.5-mm diameter and 35-mm length titanium screw was placed just lateral in the pedicle to the first screw and angling inferiorly. We could demonstrate that this screw was away from the L5 nerve opmparmvs ammomr Page 2 of 3 Copy for DAVID HADIENESS, Mo, Boulder falser Permanents • Baddor Camnwrdl-►Boulder. Colorado 80307 SCMLITE;II, LOYD 35001731 26-93-47 ADM: 07/09/97 Room 1: 2212 DIS: root and there wars no change on our nerve root monitoring system. The L4 pedicle screw was angled interiorly, with good purchase in bone. The position of the screws was monitored with lateral x-rays. Next, the bone grafting was done laterally using the best cance l ous bone between the transverse processes of L3, L4, and L5, followed by the aI electrical stimulator, followed by lamina, bone, and corticocahcellous stripe' on the top, first on the left and then on the right lateral gutters. Anse Isola rod was cut and bent and placed on the 3 slotted connectors with the middle screw using an angled washer. The nuts were tightened down on the slotted_connectors for a. rigid fixation on the left side. Thai transverse connection device wan moved distally.on the right, reconnected on the lett and then a new transverse connector rigidly applied to form a very rigid construct. Alter a final irrigation, the battery was tucked deep to the superficial fascia' layer. We made sure that the electrical- stimulator wires did not touch the hardware. They were close, near the L3 and L5 pedicle eases. A suction drain was placed in the mein incision. =osure was then done using running 1-Vicryi sutures in the deep fascia, nni,4 •� 0-Vicryl suture in the deep layer of superficial fascia, followed by aubcuticular 3-0 Prolene, Vi-Drape spray and.Steri-Stripe. The dressing was Ceroform, sterile gauze, and a Reston foam dressing. The patient was then turned supine on his hospital bed, -awakened, extubated, and taken to the post-anesthesia care unit in satisfactory condition. The estimated blood loss was 1200 cc. Fluid replacement was 1 liter of iespan, 4 liters of crystalloid, and 675 ,cc of Call-Saver blood. There were t suction drains. The sponge and needle counts were correct. There were no :implications. fILLIAM ,7_ Wfl .TEMS, MD : authorise my typed name to signify that I authenticated this report using ay personal and rni'#4 dential number. lt:cjt D: 07/09/97 T: 07/10/97 :c: DAVID Raft lies, MD, Boulder Kaiser Permanente OflPflIVI REPORT Page 3 of 3 opy for DAVID Hanisma59, ND, Boulder Kaiser Permanents • BOULDER MEDICAL CENTER;P.C. OFFICE PROCEDURE DATE: 03/05/2002 PATIENT: SCHLICHENMAYER,LOYD MEDICAL RECORD#: 00000-56-08-36 PREPROCEDURAL DIAGNOSES: 1. Post laminectomy infusion. - 2. Axial pain and bilateral lumbar radiculopathy. POSTPROCEDURAL DIAGNOSES: 1. Post laminectony infusion. 2. Axial pain and bilateral lumbar radiculopathy. PROCEDURE PERFORMED: Fluoroscopically guided intrathecal morphine test dose. REFERRING PHYSICIAN: Dr.Abrams,Kaiser. SURGEON: Melody Denham,M.D. ANESTHESIA: Intravenous sedation with Versed 2 mg. INDICATIONS: The patient is a very pleasant 63-year-old gentleman who has had severe back and leg pain since 1996. He has undergone previous fusion but unfortunately continues to have very severe pain. He states that his pain is severe with any movement and is somewhat improved by sitting. He has undergone treatments with physical therapy, anti-inflammatories, and anti-seizure medications,as well as narcotic analgesics. However,his pain level continues to be at approximately eight out of ten in severity on average. The pain is again most severe in his lower back with radiation into predominantly the left leg. He is here today for an intrathecal morphine test dose. If today's test trial is successful, then he would be a candidate for intrathecal morphine pump placement PROCEDURE: The patient was placed in the prone position. His back was prepped and draped in the usual sterile fashion. The skin was localized over the L2-L3 interspace with 1 cc of 1%lidocaine. A 25-gauge spinal needle was then introduced to the intrathecal space. Isovue 300 demonstrated presence in the spinal canal on both the P/A and lateral view. Medication given included preservative-free morphine 1 mg. The patient was then taken to the recovery room. Thirty minutes following his stay in recovery, he did report minimal pain and was awake and alert. He was instructed to record his pain level ever thirty minutes over the next twelve hours to determine whether or not he has a successful trial. If in fact he has good pain relief with minimal side effects then,again as mentioned,he would be a candidate for an intrathecal morphine pump. OFFICE PROCEDURE DATE: 03/05/2002 PATIENT: SCHLICHENMAYER,LOYD MEDICAL RECORD#: 00000-56-08-36 2 (RE: SCHLICHENMAYER,LOYD) Melody Denham, M.D. sjb DT: 03/06/2002 #125250 Pt#00000-56-08-36 cc: *Ambulatory Surgery Unit *Dr. Abrams,Kaiser Boulder,2525 13th Street,Boulder,CO 80304 . 08/26/2003 19:24 3036657532 LTS GLASS PAGE 02 I rem+ �tAre op cOt.ol te t7r.O.lylApp Ols.e S-t= ! 81 FICE� MR 7 iTATE women -- 612001 (303)Mi i1 Fce aim it"Cents'CO 80201 Watt seettgeatwasseitcse REGISTRATION OF EXISTING WELL _ H i Mamas show d er iw en 1 tang"°m+ 5--°� i ma l j elk a.ap— LC_. ex to 61101 I { Phone (4o) .fit. ! 61),0 letkilik.I 'LJ tOd t F ..rwre ws oe i♦igren c/ tvri s. 5 of b, Ia. i.e. j... T`,.-I.-- ED N.at OIL Amp_ alimaiatWe ga, _9_42„ Rt.Pore O N.44.O It, ...f..Q it.rrom O L of last sin.. 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Q .t-$h eifg S,c./.(�c�sk.nPtite rmassnmdaes"p _ ADDRESS: - 09D k4)(1.14 Cana. 4�t J�r4r.E /l W.C.as*show .002.42 $64tr r:e Co 8Q5/,1, r.03- gs3-O54,,T PHONIA 303- fIn? St -.3Q1 3 tan I WELL LOCATION: SlA us Si J vwae�_ 6 .IWP. 1 M ,RANca 6SW ,6a PM DErr. 400 - Eam*asp la /00 - Imo Sakai fl awry IA/dig arcoMo mwm,oho Rao.waaLrwn.to acv woo St _ _ CDICIJC TYRE OF=NINO WELL: Diuu, ANDIAJ fl1NO watt, OAl18RY WEL2, GRAVEL PM, OTTaEA ANY OTHER WWII LOCATEDON This PARCEL?No— YES X HOW MANY! / omit 0,d,a 0,aa? .2Ga 71S— EI:rACATED DATE MILL CON$IR[1CPED4thkrwWh DATE OP PENT UBENh41rW EVYThLTEDPtJIQINORATE 6 ipn TOTAL d aP Ann 7N]7 $TRACCIPARCEL. .3 ACRES Adds Monwooty Was Oro am_:NOM AdtWod wa6rilaa'Pw.L Wbrar(on Ngow d a[anNa ielEal.d(flowoolwor kripRoa) NAME OF AUG PLANT E8 nu: r . _ b( limoo forsom000 Se bonydwBk.) 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CHLORINE,. a.• 24 HOUR dB HOUR O A �1CIcl. -• -CLEAR M/ ER ` -�_.....- _ __ TAKEN B'• .Y REBIOUAL__ __ MG0.pH . _ r 1 COMMUNITY SUPPIY •�LT r i NONCOMMVNTTYI BOB --- ^j —___. I 1 PRIVATE ( ) PI)661C aTER SUPPLIER IDN _ •__ __ _ T _ . -- Oro Gil' 2111 SERVICE ApQhlii —, y / )--Are `!!'_ _coC-O—$6 S/ ...� BAC1>8601001CAL v�1EE6NCPJAWENCE, y��F 1..� 7!'��-G-i_� "/ - e4 - _._ . *awe ht$rIa8ULT • _ C -, _, iU6DNIS10N __ y . __-,__ RESULTS — BECTION____..6.?..... _.. ,>YN&10 .!!J�t'h RANGE 4"O TOTAL COi100 ML M RETURN To_.._ay RL___1`Y((�!„4 n/+ t✓ E. _.. So O COMMENTS G ADDRESS _. 9_ W G le -- PHONE 1520.C. °/3 _ i? ------- 112 PRlSUKE OF COUFDIUI INDICATES NON-COMPLIANCE 5 o SEE REVERSE FOR SAMPLE IN6tRVCTgNS ANL UC4'NITIDNB nem MMMIUM DRINKING PAM STANDARDS IRM MC) * ` . 6 -ooDo�3a O Kit WISP�. Department of Planning Services Flood Hazard Development Permit COLORADO Administrative Review • Applicant: Loyd and Sheila Schlichenmayer Case Number: FHDP-361 Planner: ko Legal Description: Lot B of RE-761; Part of the SW4 of Section 6, Township 1 North, Range 68 West of the 6th P.M., Weld County, Colorado Parcel Identification Number: 1467 06 300004 Firm Map Number: 080266 0960 D Permit is approved -The plans and materials submitted in support of the proposed development are in compliance with the applicable floodplain management standards in the Weld County Zoning Ordinance. Permit is conditionally approved. Provided the conditions of approval are met, the plans and X materials submitted in support of proposed development will comply with the applicable floodplain management standards in the Weld County Zoning Ordinance. Permit is denied. The proposed development is not in conformance with applicable floodplain management standards in the Weld County Zoning Ordinance (explanation attached). Variance is required. The proposed development will require approval of a variance by the Board of Adjustment is the applicant wishes to proceed with construction. Please call the Department of Planning Services to discuss the appropriate application materials needed to apply for a variance. 1. The applicant has supplied adequate documentation which has been verified, stamped, and signed by a professional engineer. Elevation of the lower floor of the proposed structure is at least one foot above the intermediate Regional Flood Level (Mean Sea Level) at the building site. This is a non- residential structure. Conditions of Approval: 1. All new construction and substantial improvement will be anchored to prevent flotation, collapse or lateral movement of the structure and to withstand hydrodynamic loads. 2. Installation of utilities shall comply with the conditions listed in the Flood Hazard Development Permit Certificate. 3. Construction shall comply with all requirements/conditions of the Weld County Building Code. 4. The lowest floor elevation of structures without a basement shall be considered to be the elevation, above mean sea level, of the top of the foundation of the structure. The lowest floor elevation of structures with a basement shall be considered to be the elevation, above mean sea level,of the floor of the basement of the structure. The lowest floor elevation of a mobile home shall be considered to be the elevation, above mean sea level, of the top of the mobile home pad;-as described in the Lowest Floor definition in the Weld County Zoning Ordinance. (Also, see definition of BASEMENT: Any floor level below the first story or main floor of a building. The BASEMENT is wholly or partially lower than the surface of the ground. For the purposes of this ordinance, any crawl space with six (6)feet or more between the floor and the ceiling shall be considered to be a BASEMENT). 5. Prior to release of the Certificate of Occupancy or building permit final approval, the applicant shall submit an as-built elevation certificate signed and stamped by a registered Colorado Professional Engineer to the Department of Planning Services. 6. All proposed or existing structures will or do meet the minimum setback and offset requirements for the zone district in which the property is located. 7. Any future structures or uses on site must obtain the appropriate zoning and building permits. 8. The red shipping container located northeast of the residence shall be removed from the property or screened from all adjacent properties and public rights-of-way. The property is in violation of the Weld County Zoning Ordinance. The applicant shall schedule a final inspection with the Weld County Zoning Compliance Officer and submit a copy of the closure letter indicating compliance with the Weld County Zoning Ordinance. 9. The applicant shall obtain any required demolition permits from the Weld County building Inspection Department and conduct asbestos related inspections as required by Regulation 8 of the Colorado Air Quality Commission. t �\ March 31.2000 Kim Ogle, Plann Date IDDEPARTMENT OF PLANNING SERVICES PHONE (970)353-6100,EXT.3540 O FAX(970)304-6498 E-mail address:kogle@CO.We1d.CO.US • WELD COUNTY ADMINISTRATIVE OFFICES COLORADO 1555 N. 17TH AVENUE GREELEY, COLORADO 80631 March 14, 2000 Loyd and Shelia Schlichenmayer 5090 Weld County Road 1 Erie, Colorado 80516 Subject: Flood Hazard Development Permit (FHDP) Parcel #: 1467 06 300004 Dear Loyd and Shelia Schlichenmayer: The Departments of Public Works and Planning Services has reviewed your application for a FHDP - and has the following comments: First, the information provided in your application appears to be inaccurate. I am enclosing the correct map that identifies your residence (see yellow circle) with the appropriate contour notation. Please note, your residence lies between contour interval 4976 and 4978. Referring to page 7.of the FHDP application, Mr. Gaz states the water surface elevation of the Intermediate Regional Flood is 4975 feet above MSL for the building site. He goes on to state the lowest floor elevation of the proposed structure is two (2) feet above the MSL at the building site. Further, the elevation of the lowest floor of the pole barn is at 4976 feet above MSL at the building site, (slab on grade). Based on these calculations, water elevation of Intermediate Regional Flood at MSL 4975 feet plus 2 feet above MSL at building site equals 4977 feet above MSL at building site, not 4976 as noted on the application. Second, the Department of Public Works has determined your building site elevation to be approximately 4977 feet above MSL. Therefore, with a building height of one foot out of the flood plane, the height of the lowest floor elevation of the pole barn should be approximately 4978 feet above MSL at the building site. Due to the discrepancy in the calculated numbers of the proposed building site, the Departments of Public Works and Planning Services is returning your documentation relative to the engineered calculations for review and modification. Should you or Mr. Gaz, your P.E. wish to discuss this issue of other issues associated with this letter, please contact either Don Carroll in the Public Works Department at 970/ 356 4000 x 3750 or myself at 970 353 6100 x 3540. Sincerely, Kim Planner II enclosures pc: File FHDP 361 Don Carroll, Public Works Lin Dodge, Building Department , Health Department ll 1 Veld County Building Inspection Departme, 1555 North 17th Avenue,Greeley,CO 80631 970-353-6100,Ext.3540 Fax: 970-304-6498 Permit# BC-0000320 Status ISSUED Applied 04/19/2000 Issued 05/19/2000 Expires 11/15/2000 Job Address 5090 WCR 1 WEL Job Location 5090 WCR 1 - Job Description 8000 SF POLE FRAME GARAGE/STORAGE SHED W/PARTIAL SLAB& PLUMBING,HEATING/ELECTRICAL AND WATER SERVICE. Occ.Class U-1 Construction Type: VN Zone District AGRICULTURAL Parcel Number 1467-06-3-00-004 1997 UBC Valuation$98,800.00 APPLICANT SCHLICHENMAYER SHEILA 04/19/2000 Phone: 303-828-3013 5090 WCR 1 ERIE CO 80516 ELECTRICAL KPI ELECTRIC 04/19/2000 Phone: 303-828-0275 CONTRACTOR QUALITY POLE BARN 04/19/2000 Phone: 303-828-3975 OWNER SCHLICHENMAYER LOYD&SHEILA04/19/2000 Phone: 303-828-3013 5090 WCR 1 ERIE CO 80516 Minimum Required Zoning Setbacks N- 8 S - 8 E- 8 W- 95 FEE SUMMARY Total Permit Fees $1,016.00 Total Payments .00 Balance Due $0.00 FEE BREAKDOWN SUMMARY Item# Description Account Code Tot Fee Paid Pry. Pmts Cur. Pmts Balance 2010 Building Permit 100025100-42 881.00 881.00 881.00 .00 .00 2020 Electrical 100025100-42 85.00 85.00 85.00 .00 .00 2040 Building Plan C 100025100-42 50.00 50.00 50.00 .00 .00 NOTICE The applicant,agents and employees shall comply with all the rules,restrictions and requirements of Weld County Zoning and Building Code Ordinances governing location,construction,demolition and erection of the above proposed work for which this permit is granted.The building Official is authorized to order the immediate cessation of work at any time a violation of the adopted codes or regulations appears to have occured. Violations of any codes or regulations may result in the revocation of this permit. Buildings must conform with the plans as submitted to the Building Inspection Department. Any changes to the plans or lay-out must be approved prior to construction. Any changes in the use or occupancy of the building must be approved. It shall be the duty of the property owner or the person doing the work authorized by this permit to notify the Weld County Building Inspection Department that such work is ready for inspection. This permit shalt expire by limitation and become null and void if the building or work authorized by this permit is not commenced within 180 days from the date this permit is issued,or if the building or work authorized by this permit is suspended or abandoned at any time after the work is commenced for a period of 180 days. Before such work can recommence a new permit shall be required and the charge shall be 1/2 the fee under the current Weld County Building Inspection Fee Schedule provided that such suspension or abandonment has not exceeded five(5)years. When suspension or abandonment has exceeded five(5)years,the permittee shall pay the full permit fee under the current fee shcedule. Weld County is not liable for workmanship. Permits are not transferable. form:BldgComb letsDL E W ING PERMIT APPLIC,"-"ION ELECTRICAL �1LY YES NO 1555 N. 17TH WELD COUNTY BUILDING INSPE �N AVENUE GREELEY, CO 80631 Wilk _ (970)-353-6100 EXT. 3540 /3 .. DO �� COLORA �IPLOTcPLANS AND WARRANTY DEEDREQUIRED FOR ALL STRUCTURES PROPERTY OWNER '45 `'hg1 in. SO-i I 1 GV2L.k Mt2 f°e 1' PHONE . gyp. F71'O11.--, 1:7/3 MAILING ADDRESS SO 90 CL) L' R / EF-i•8. CI) 'D S/(r JOB SITE ADDRESS SC/11 ri r o LEGAL DESCRIPTION SEC. `9 I,T N, R e aQ W I DISTANCE FROM LOT L NES �� /� OR SUBDIVISION+ LOT BLOCK I N-/-17!-S I n IN f""" thJ GENERAL CONTRACTOR MAILING ADDRESS ID# PHONE -',a1, / 1 a1,, f j- 123-,W--(3,15 MECHANICAL CONTRACTOR MAILING ADDRESS ID# PHONE ELECTRICAL CONTRACTOR MAILING ADDRESS ID# PHONE !� I J Elea,-i c 3o?-4a1-7/12s PLUMBING CONTRACTOR MAILING ADDRESS ID# PHONE • PURPOSE FOR PERMIT TYPE OF PROJECT TYPE OF CONSTRUCTION TYPE OF FOUNDATION „Iii1EW BUILDING O DWELLING O WOOD FRAME O BASEMENT ❑ ADDITION dirPRIVATE GARAGE 0 STRUCTURAL STEEL O FINISHED-SF: O REMODEL 0 ATTACHED16ETACHED O MASONRY 0 UNFINISHED-SF: O REPAIR/REPLACEMENT O SINGLE O 2 CAR + 0 REINFORCED CONCRETE 0 CRAWLSPACE: SF ❑ ELECTRICAL O PUBLIC GARAGE 0 BRICK VENEER SLAB ril/ti•a/ O MOVE-IN RESIDENCE STORAGE HEDPOLE FRAME 0 CAISSONS ❑ OTHER AT-OTHER `2 0 OTHER 0 OTHER HEIGHT OF BUILDING: t!:?1 ✓•OF STORIES: o� # OF FIREPLACES MASONRY: _O-CLEARANCE: __._.GAS LOG: - CARPORT SIZE: -X- PATIO: 1ST SIZE: -X- 2ND SIZE:__....X - COVERED: 0 YES 0 NO NUMBER OF BEDRI : DECK: 1ST SIZE: -X_ 2ND SIZE:-X- COVERED: 0 YES 0 NO BATHROOMS d L: 3/4: /2:— PLOT PLAN ON FILE: O YES 0 NO BLUEPRINT ON FILE: O YES 0 NO TOTAL LAND 'REA: Of cry'S DRIVEWAY ACCESS: 0 EXISTING O NEW--❑NORTH OSOUTH❑EAST❑WEST ❑ SINGLE FAMIL ■ O OR MORE FAMILY 0 MOTEL/HOTEL#OF UNITS 0 OTHER TYPE OF SEWA TYPE OF WATER: TYPE OF HEAT: ELECTRICAL SE I E O PUBLIC-NAME: O P BLIC-NAME: r� ❑ T. GAS-NAME: 0 NAME: 1 rii:Pa Poe-'er- PERMIT #:I-Ii �`7 PERMIT #: 02�! ! �� ELECTRIC-NAME: CALCULAT ONS: AMPS PERC.TEST DA : 0 OTHER SQUARE FOOTAGE VALUES .S$rA''_ BUILDING FEE S "NOT TO INCLUDE THE FOLLOWING ITEMS IN THE ABOVE PRICE`" -�� MAIN LEVEL: f� DP, LEVEL: a ELECTRICAL COSTS $ SWa FEE S 9 Q FOUNDATION: CONSTRUCTION METER: O YES AL-1 0 FEE $ 7/M /d GARAGE: . PLAN CHECK: RYES O NO FEE S SO-OO a` lo'�„�j nTHER: OTHER : FEE $ `�- TOTAL FEES S More than one{1) residence on site? Yes No INCLUDE A BREIF DESCRIPTION OF THE WORK BEING DONE LISTING THE INTENDED USE `IUD 1,E Ski ki•/Q/iv Afd X . -UD Czir-Q�p:� I HEREBY CERTIFY THE ABOVE AND ANY ATTACHED INFORMATION IS CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE: ��/g 00 SIGNATURE OF APPLICANT pia a i��i(�1///,2� - '`7� DATE • • • (Space Above rile Line For Recording Data( Loan #: 326977 DEED OF TRUST THIS DEED OF TRUST ("Security Instrument") is made on May 28th 1998 , among the grantor, LOYD SCHLICHENMAYER and SHEILA SCHLICHENMAYER ("Borrower"), the Public Trustee of WELD County ("Trustee"), and the beneficiary, DOMINION MORTGAGE CORPORATION , which is organized and existing under the laws of COLORADO and whose address is 3050 BROADWAY, SUITE 300 Boulder, CO 80304 ("Lender"). Borrower owes Lender the principal sum of One Hundred Thirty Five Thousand and 00/100 Dollars (U.S.$ 135,000.00). This debt is evidenced by Borrower's note dated the same date as this Security Instrument ("Note"), which provides for monthly payments, with the full debt, if not paid earlier, due and payable on June 1, 2028 This Security Instrument secures to Lender: (a) the repayment of the debt evidenced by the Note, with interest, and all renewals, extensions and modifications of the Note; (b) the payment of all other sums, with interest, advanced under paragraph 7 to protect the security of this Security Instrument; and (c) the performance of Borrower's covenants and agreements under this Security Instrument and the Note. For this purpose, Borrower, in consideration of the debt and the trust herein created, irrevocably grants and conveys to Trustee, in trust, with power of sale, the following described property located in WELD County, Colorado: LOT B OF RECORDED EXEMPTION NO. 1467-6-3-RE761 RECORDED DECEMBER 2, 1985 IN BOOK 1093 AT RECEPTION NO. 2034134, BEING A PORTION OF THE SOUTHWEST 1/4 OF THE SOUTHWEST 1/4 OF SECTION 6, TOWNSHIP 1 NORTH, RANGE 68 WEST OF THE 6THE P.M., COUNTY OF WELD STATE OF COLORADO • which has the address of 5090 WELD COUNTY ROAD 1 ERIE Street City Colorado 80516 ("Property Address"); Zip Code TOGETHER WITH all the improvements now or hereafter erected on the property, and all easements, appurtenances, and fixtures now or hereafter a part of the property. All replacements and additions shall also be covered by this Security Instrument. All of the foregoing is referred to in this Security Instrument as the "Property". BORROWER COVENANTS that Borrower is lawfully seized of the estate hereby conveyed and has the right to grant and convey the Property and that the Property is unencumbered, except for encumbrances of record. Borrower warrants and will defend generally the title to the Property against all claims and demands, subject to any encumbrances of record. THIS SECURITY INSTRUMENT combines uniform covenants for national use and non-uniform covenants with limited variations by jurisdiction to constitute a uniform security instrument covering real property. UNIFORM COVENANTS. Borrower and Lender covenant and agree as follows: L)C,V/ II c-V/ Cvirr/lyer < 020o ' la ' , _ ocr ' 3a " .' Lofts O-a/y.tti roan, C-ara/¢i Traci 7 . 'Door Mir t v pi 0 I; m' I" E 1..-'311d1•Adi Yv 0 4 tt e t-L i-N'tTr.LLV�_ riding; O'etta�:1- -.. TA:kapaoeOad= (303)443=700L 3 N ASPHALT DRIVE N \ \on ao Sn 0 A N n oS 0 Jul 20.4* o 13.0' a \\ 3, V I5.3 u - \ 29.3' y u ONE—STORY 3,1• \ a BRICK HOUSE DETAIL \ to HOUSE N/GARAGE SCALE 1"=40' \ G 54.8' saanrailii...- \ Ca II CRAWL "RFo SPACE ACCESS t l J Le, N se fa Pole Su.tldrng --1 .. Z pp�xsi ' , oo , i _ 3 i , lad . P � I lb tN �. Ip � 'A � • u, "5o s 1 P :tie Commitment No. LR18672898 was entirely relied upon 1 I S' its of record. I 1 I B 1093 -.SC 02034134 12/02/85 16: • $6.00 1/002 - F 1638 MARY ANN FEUERSTEIN CLERK &~RECORDER WELD CO, CO Recorded Exemption No, I467-63- RE 761 NESTviEw. ESTATES II IS00°05'33W- 300.00'wJ i , .....,,,,. • ••0 _... ._ 1 162.241 137. 76 0.5 2 - I • I Q o CD co �n a tr5 (V I...: N- Ir • N- fii I !L LOT B .MM LOT A , - 3.000 Ac. 2.000 Ac. - O .100 0 100 U tT'_ • co to- scale 1"=100' O 2 O -jto'utility 0Easement to i> SOO°0533"W~ • E is 2ti _W 47 76 n w w 1n p . c to it to O 8 :sm. E to O m i� N 0 I' mi o I o N . _ °' 0) co 4aN " CO Q Z n _ rill j M ____ 210.00 EC , 90.00 . za'Access Easement a Utility Easement o WELD ib COUNTY ROAD bN0. I i0 Fnd.5/8" Iron Pin 02IO.00l 90.00 in , 0 1100°05133"E West Line Sec. a--•• NOO°O5'33"E 300.00' 300.3 S.W. Corner 1.) I .-I ~'J True Point Section .. Pt I,� _ % of Beginning 4457 MIKERAL / • w Nap' /• / . 1.--/y to'� NOTES: '•x ; 1 . The basis of bearings is N00°05' 33"E for the West line of Section 6, �-F I ' • 7. , T1N, R68u' from the recorded plat of • .. . Westview Estates. C . `1, � 2 . Indicates set 3/4" I Brass disc WEST VIEW D. �. .� — • .'.`., :, with LS 5648 1 a k / .///:,--• _'J ( `C •� '") 3. Indicates set 5/8" Rebar with i ' ‘ �' I.1 • .. `' t -- Aluminum Cap bearing LS 5648 .7-f, .y -- - ._..-\,, - • - • • r (..--7,-1.,"/ )yi,! V 4. Indicates found Pin and Cap 1L.,_..."(//,-)„,r1///____ , \, 5. O Indicates set 1i" x 2,-0" C' ` �► Pipe over .Pin to Ga•p ,� JJ /' I Prepared by K.E.N. 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