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HomeMy WebLinkAboutBLD2004-00585 �, MLA04-00551 BUILDING PERMIT APPLIC�i!;ON Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-005R5 Received Date: 9/17/2004 SITE ADDRESS: _i''. I '-',,�,,',- %'` PORT LUDLOW, 98365 OWNER: RAY E CULVER PHONE: 30 RIVERDALE CT QUILCENE WA 983768557 SUBDIVISION: TRAIL'S END 3RD ADD Block: 6 Lot: 19 PARCEL NUMBER: 950200625 Section: 16 Township: 27 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOD DECK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP DEK MAIN: 100 VALUATION 2,357.00 ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: Exist: Wetland Erosion Prop: Prop: Seismic Streams Total: Total: Flood Way Floodplain Routing Date: / F&W Landslide /7 �%� Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $83.25 INT 09/17/04 67647 APPROVED Plan Check $54.11 INT 09/17/04 67647 State Building Code $4.50 INT 09/17/04 67647 MAR 3 02005 Total: $141.86 Jefferson County Planning &Building Department Piib • BUILDI NG PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD04-00585 SITE ADDRESS: 391 S BEACH DR Received Date 09/17/2004 PORT LUDLOW, 98365 Issue Date 03/30/2005 APPLICANT: RAY E CULVER � 30 RIVERDALE CT PHONE:" (05-QI �0Q QUILCENE WA 983768557 - ` vv SUBDIVISION: TRAIL'S END 3RD ADD PARCEL NUMBER: 950200625 Block: 6 Lot: 19 Section: 16 Township: 27 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: PROJECT DESCRIPTION: DECK CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. SETBACKS: 6k 3/t5/44,1 UFFER: iU/4 Footing: -fkQ P OK 3//s104 Foundation: A/4 Stormwater FINAL Approval: WA Underground Plumbing: WA Underground Insu ation: /II4,A Shear Wall : L1 Sheathing: N/,A Framing: OKC, 3-10/6-4, Plumbing: A94 Propane Tank Lines: Insulation: A1, Sheetrock: #J7A Septic Sytem Final Approval (If not on sewer): i9A Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: • r.F. ` HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQ IR D PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. HOT LINE AVAILABLE 24 HOURS A DAY • • SPECIAL CONDITIONS APPLY - SEE REVERSE 4.0,PE�S 5-r-re•D '. 8/7/67 SPECIAL CONDITIONS FOR CASE A BLD04-00585 • 1.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 2.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 3.) Prior to and during approved construction activities, the perimeter of the landslide hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 4.) All construction activities shall not encroach upon the buffer. This includes the storage or preparation of materials. 5.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or'any other prominent physical marking approved by the UDC Administrator. 6.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 7.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 8.) MANDATORY MEASURES OF HIGH RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. • 9.) MANDATORY MEASURES F HIGH RISK SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirements: a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106 for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC 173-160-171 (i.e., within 100 feet of a groundwater source showing chloride concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an existing or proposed groundwater well not subject to an Ecology variance, applicant must provide evidence through a hydrogeologic assessment (relevant components of an Aquifer Recharge Area Report per UDC 3.6.10.e) of a reasonable probability that the subject aquifer will not be degraded by the proposed use of well. b. Installation of a flow meter. c. On-going well monitoring for chloride concentration. d. Submittal of flow and chloride data to the County per monitoring program. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 10.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 12.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any lot less than one-half acre unless totally screened from view of neighboring dwellings and rights-of-way. Such screening shall meet all applicable performance and development standards specific to the district in which the storage is kept, and shall be in keeping with the character of the area. Screening shall meet the requirements of Unified Development Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable vehicles is prohibited except in those districts where specified as an automobile wrecking yard or junk (or salvage) yard and allowed as a Permitted Use in Table 3-1 of the UDC, and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area (ESA). 13.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 14.) The building height is not to exceed 35 feet. 15.) Minimum setback from S Beach Dr right-of-way is 20 ft. Minimum side and rear setbacks are 5 ft. Environmentally sensitive areas further impact setbbacks. 16.) A stormwater plan for a medium project has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 17.) A Geologic Assessment Report prepared by Alkai Consultants LLC dated March 15, 2005 was submitted in conjunction with this application. The report addressed the stability of the geologic hazard area. A setback of 30-feet shall be measured perpendicularly from the top or toe of the geologic hazard to the proposed deck. 18.) Roof drains for any structure be tightlined to the toe of the slope near the primitive roadway and an energy dissipater such as quarry spalls be utilized to reduce erosion. 19.) Vegetation should be maintained as currently established outside the building and driveway areas. 20.) All permanent or dwelling structure footings shall bear on firm native soil. • I:\F_BLD_Permit_Buildng.rpt 10/29/19 • • le� ° 1111 � JEFFERSON COUNTY 1-3 +-� DEPARTMENT OF COMMUNITY DEVELOPMENT y, 4.* 621 Sheridan Street • Port Townsend • Washington 98368 O 360/379-4450 • 360/379-4451 Fax N http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# PROJECT/APPLICANT NAME: y C V l i Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate stormwater site plan map. Project Overview 1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the site map. ' ! /� vvuoV Q C'�Q�Z. u�( if e� c", L 0,/". .0 Ye": `Co�\\ -crowd Ne1.G\Clbar''S tAno5f P\b JR Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. 3co o slo p 3. Describe the existing vegetation. Indicate native v(v„ettation areas on the site map. M 11-see--esQc c7`\ W�tit5 " n s -- [3/Gc k 1\ev,rys- 4. Describe the existing soils. lnd'cate soil type on the site map. L_o Tc,f So. 5. Describe the existing site hydrology(i.e., drainage;behavior of water on the site—above, below, and on the ground). Indicate existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if applicable,and indicate creage of each) /20 57Pf?),--# -to Co\)e 1luvA.oQ 4(c)vv. c.Cx u Q. , (�eTat+� atnc� tC ' C(s t` i c\- o_s -LSS ��O\�. ���.�`'� ,r wc.$r ±e -jvvF9Ay lave._ tn CA o \ lc 03 lea ` rck.w \ c \€s• te..b. 9f c 9S Ect 6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED nn , - STORMWATER PIJAN IV MAR 2 8 2005 JEFFERSON COUNTY 5 stormwater site plan template—rev.10/1/2003 DEPT.OF 'OMMUNIT,Y0? dolt PMEN L SIGXAT - IiNV MI� • • . 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the site. Indicate location on the site map./©©" tnboVC. .v ou52. vet` f)4,( 1 5e_yt. 5 �c21 -- `OkI�.v- 'H- -1_w'V1 k �vikin 2.7 / /0v1 �C) Lw c v-eU,. Cc�. `"L`e \cor ., fi.� t e - &ev So,A- f`�n-� .K- Z.oc . 8. Describe the general vicinity of the site,including adjacent land uses and structures, utilities, roads,and sensitive/critical areas streams,wetlands,lakes,steep slopes,`\etc.). ,`19v[A`Qt(' NeV5n� 0;& f\er 4 . —1fie 'ls G►z1ue\ �. e�,� o�e.Y s �toX aoo UJCA (OX. Li DO ' 136- ,l. 0 'i' -�hc /y,')! otie yearQ_�'c�v o J*V /Vex-1- fio ;v�e ,, M C)&* ,s rye G,`►�-1 -Zr unoff Rele v wV A-boti . [ I�{un5- -Ai•e t tsV- Permanent Stormwater Control Plan This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs and facilities to remain in place after construction of the project is completed. "Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control facilities are not exceeded. 9. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30 in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas within the site. Locate these facilities on the site plan and differentiate roposed facilities from existing facilities. f2C-a4"t� C..o 'Yo\ \ow o(7 Id,:el wa.Ver w:k-A Rol(N. ATV. gay ga.y "&,\e-:"-%-Grams)- #lav1,,S —'Tre--e5 —7- oc tc'\-. 10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is normally for large"projects or projects that involve the potential for dispersion of contaminants.] Ak 11. Describe the rformance goals and standards applicable to the project. � n re_V � /-1 ll�r��Oos ti vv� G� _o0•e. U)ram l-e t(' tip /2b t ,P Sot./.c 7D1- ��.,_ ) )Vf fr►CJ'tk 0 -1AN-9z_ chA rS 1 - 12. Describe the flo}"'control system. /as -74' At.)-„evli''�r-, ?ovak O k plow 4- Cov„k-1"0 di - . le 5 —re; -P/ow. No. Ue. • To Se- 5c \4 ,irKiva ( i stormwater site plan template—rev.1041P,4 M),'' ? f 6 ? y • • 13. Describe the water quality system. \Nk 14. Describe the conveyance system analysis and design. 15. Describe the source of fill material,physical characteristics of fill terial,and deposition of excess material. SC ov .��.. " -Top o I 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. N 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. 19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for "large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals here. N 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. \N 21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or restrictions here. Prc- stormwater site plan template—rev.10/1/2003 7 • • CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN (SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential development. SECTION I—CONSTRUCTION SWPPP NARRATIVE 1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page 2-15). 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. Pt'In. ` j,r. 2. Establish Construction Access. vv-vv r \ e, Mtn NA". 3. Control Flow Rates. /1cc , Fefv, - — Grc s 4. Install Sediment Controls. 5. Stabilize Soils. 67vc;Ss 6. Protect Slopes. r t�� 1-0 a„,n_c WcA,ejir- k 0 _ovv -o i) 1 to j 7. Protect Drain Inlets. stormwater site plan template—rev.10V1/2003 8 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. Gross 9. Control Pollutants. 9 V 10.�C_oontrol De-Watering (the act of pumpin groundwater or sto water away from an active con truction si e). 1 o v�� %�. i f� � �v vvt tPe "1'0 Ct,1e\A-1/c \ j O-N. • 11. intain Best Management rracticePractices(BMPs). *.k 1 Y 6+n5t'+e 1 a sp. o "D/ ie, CVA-170)/. 12. Manage the Project. 1.)("t I y o y c f 1/ ,"- 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). N b. Description of the downstream drainage path leading from the siteto the receiving body of water(minimum distance of 400 yards). D'i s t\`OVvc1\ s��P ec�ti�C c>G4. -lbvrvtev' N&$()(\ 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. PD, X I OHO vJ c tAn stormwater site plan template—rev.10/1/2003 9 • . . b. Description of special requirements for working in or near environmentally sensitive areas. f\i' oc 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure). N lk 5. Construction Phasing. a. Construction sequence b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. c\::t A. Wet Season Construction Activities. a. Proposed wet season construction activities. 'Pk 01.-— TV-e.t.5 b. Proposed wet season construction activities fort environmentally sensitive areas. el t✓C.� to 1 g-p (11 �', e.k eA Col l� A-5 .op in 2a ri4• /-/G. vti- 7/e--e s 7. Financiaf/Ownership Responsibilities. a. Identify the property own r responsible for e ipitiation of bonds and/or other financial securities. �r z L�.1v,e.-- b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. N P L 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. Nc . c. Waterways. k-- d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.10/1/2003 10 • . SECTION II—EROSION AND SEDIMENT CONTROL PLAN Sediment and erosion control measures may be depicted on the master land use application plot plan,a stormwater site plan,and/or a separate Construction SWPPP site plan. This is a checklist to ensure that the following are depicted on a site plan: 1. General. a. Vicinity Map b. Jefferson County Approval Block c. Erosion and Sediment Control Notes 2. Site Plan. a. Legal description of subject property. b. North arrow. c. Indicate boundaries of existing vegetation(e.g.,tree lines,pasture areas,etc.). d. Identify and label areas of potential erosion problems. e. Identify FEMA base flood boundaries and Shoreline Management boundaries(if applicable). f. Show existing and proposed contours. g. Indicate drainage basins and direction of flow for individual drainage areas. h. Label final grade contours and identify developed condition drainage basins. i. Delineate areas that are to be cleared and graded. j. Show all cut and fill slopes indicating top and bottom of slope catch lines. 3. Conveyance Systems. a. Designate locations for swales,interceptor trenches,or ditches. b. Show all temporary and permanent drainage pipes,ditches,or cut-off trenches required for erosion&sediment control. c. Provide minimum slope and cover for all temporary pipes or call out pipe inverts. d. Shows grades,dimensions,and direction of flow in all ditches,swales,culverts and pipes. e. Provide details for bypassing off-site runoff around disturbed areas. f. Indicate locations and outlets of any dewatering systems. 4. Location of Detention Best Management Practices(BMPs). Identify location of detention BMPs. 5. Erosion and Sediment Control Facilities. a. Show the locations of sediment trap(s),pond(s),pipes and structures. b. Dimension pond berm widths and inside and outside pond slopes. c. Indicate the trap/pond storage required and the depth,length,and width dimensions. d. Provide typical section views through pond and outlet structure. e. Provide typical details of gravel cone and standpipe,and/or other filtering devices. f. Detail stabilization techniques for outlet/inlet. g. Detail control/restrictor device location and details. h. Specify mulch and/or recommended cover of berms and slopes. i. Provide rock specifications and detail for rock check dam(s),if applicable. j. Specify spacing for rock check dams as required. k. Provide front and side sections of typical rock check dams. I. Indicate the locations and provide details and.specifications for silt fabric. m. Locate the construction entrance and provide a detail. 6. Detailed Drawings. Any structural practices used that are not referenced in the Ecology Manual should be explained and illustrated with detailed drawings. 7. Other Pollutant BMPs. Indicate on the site plan the locations of BMPs to be used for the control of pollutants other than sediment(e.g.,concrete wash water). 8. Monitoring Locations. Indicate on the site plan the water quality sampling locations to be used for monitoring water quality on the construction site. Sampling stations should be located upstream and downstream of the project site. stormwater site plan template—rev.10/1/2003 11 i • Stormwater Site Plan Changes If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change. Final Corrected Plan Submittal If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs (not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as constructed. APPLICANT SIGNATURE By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of t a ected property. /7(Y/61Y ( WNER O�JTHORIZED REPRESE TIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: :.. 1!........ _ 1 . ..... `. stormwater site plan template—rev.10/1/2003 12 4c' ��goly e06. JEFFERSON 4NTY ^� ,� DEPARTMENT OF COMMUNITY DEVELOPMENT 41 `� 621 Sheridan Street • Port Townsend •Washington 98368 I � l „ '' "� ll% 360/379-4450 • 360/379-4451 Fax I i 410 .qs a•p/ www.co.jefferson.wa.us/commdevelopment '" �tIN� i. 1 7 % � Master Permit Application MLA: l 01 - cj Project Description(include rate sheets as necessary): PT. Or L_: . : t �_u ec K _ Tax Parcel G Property '^i i Number: l 5-0— —QS-4 Size: G ?i/ 8 (acres/square feet) Site Address and/or Directions to Property: S c r • Property Owner(s)of Record: y C u U e cr Telephone:_3642)-7g S---- I 3 l Fax: email: Mailing Address: 3c -R;cpecl\,e "Or &.J..,C i f v,S( gQ37C,, Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) P Building 0 Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑Conditional Use[C(a),C(d),or C]** ❑Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached 0 Special Use(Essential Public Facilities)** ❑ Manufactured Home 0 Boundary Line Adjustment ❑ Modular ❑Short Plat** ❑Commercial* ❑ Binding Site Plan** ❑Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** tormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate Se to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: 9,97e>y By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide a s and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required inspections.Access and righ f e to this property shall be requested and shall occur only during regular business hours. �C C� (1 Signature: —✓> �/ Date: / l7 O The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"E A."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued wil violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you ar I mpliance with the Jeffe County development code.The Applicant acknowledges that he,she or it holds individual and non-transferab r ponsibility for • t d complying with the ESA. The Applicant has read this disclai '--r`an signs and dates it below. Signature: Date: 9 l ` D� G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc OWNER BUILDER STATEMENT — !� r The signer of this statement does hereby certify they are the Owners of the parcel referenced herein, ey t- r dt li sed contractors and that they will be assu ' the respon 'bill the General Contractor for the proposed project 1 vv l Signature: L_.....------ Date: y/04/ i GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) 4 'PIG"' CI a ;. MAILING ADDRESS: EMAIL: CONTRACTORS LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: ' PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: F9,ne Type: Bathrooms: Shoreline: Type of Sewage Disposal: VNew Wood Existing: 0 Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: 0 Individual System ❑ Repair 0 Masonry SEP Permit# Bedrooms: Water ❑ Demolition ❑ Other: Existing: Setback: Supply: ❑ Private well ❑ Two Party Type of Heat: Proposed: - ❑ Public Total: Name of System: If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: ❑ Underground Tank ❑ Above ground Tank Size of Propane Tank: ❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage For Office Use Only ,n=s Current Proposed Amount Main Floor Consistency Review:/&6 " 2"t'Floor Base fee: .„ a ) 31.0 Floor - -7 . } , II Mezzanine: Plan Check fee: ----- seated Basement State Surchar'gefee: wh; , i p �. Inheated Basement Pot Water Revieitifee: �� �����M1h,;; :: :- )ther Unheated 911/Rd Approach fee: 'r. ',51.,',.: '1.--A ,c,A . —1 ;arage/Carport TOTAL $ 1-" t,8fo iecks f O l!1p 5 g 35-1 Receipt Number: 6 1 )ther ors Cash/Check Number: © a ESTIMATED COST(REQUIRED) Date: {,}' f--)/0 Fair mark/ value of all labor and materials foundation to finish -* Initials: PemritCenter\FORMS\DAD FORMS\Master Permit Application 7-8-04.doc . we(:;1 t • - ' ,, , k.). u,,,.. — .E' 3 0 ---)". 'I ,....— ,-. -,(1' • e, , 04'tYklit) le_ da 1 v ' 0 MO 51 Pt" • _. --,4 ...: ..„ . ., ... .- ......_ \ s,,,...,,t,.;.. 0a .. . - •.,, -. ----_______ IA' i rs f''.. ' ,. .__ /7, •,„ ,,) „ ( , .. • # cork\o, wooas _ 4.yr •-.7) --'--- Ti t.C., A...,,,,,,....._ .„ ........_.. ._..,_ ... . ....,.. ...,.......__....... . : . . . _--- ....,..... ___________ ... ) 'n( „/".,, . 4 ',!,' '• / , S ; te... • , re / To --6-.. ..., ' CA ec.A.ce.k 1 1 1 APPROVED , SITE PLAN 't. 1 MAR 2 8 2005 0 if i V . . JEFFERSON cowry DEPT.OF COMMUNITY b,..:LOP • A SIGNATUR= — " 41',ImmairAdiwassw11-"" 'Aiimimme.ms..;.iij 4 i . j / ' • e(Ac;'r NT.3