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HomeMy WebLinkAboutBLD2004-00586 • I MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD04-00586 Received Date: 9/20/2004 SITE ADDRESS: 564 TOTEM RIDGE RD Issue Date: 12/6/2004 PORT HADLOCK, 98339 APPLICANT: HARVEY WINDLE SUSAN WINDLE P 0 BOX 1482 PORT HADLOCK WA 98339 SUBDIVISION: W E SETON SHORT PLAT Block: Lot: 3 PARCEL#: 901114024 Section: 11 Township: 29 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: CELSO LAMAS WAINS1420 Expires: 2/28/2007 WASHINGTON HOME CENTER SHELTON WA 98584 PROJECT DESCRIPTION: NEW MAN HOME MAKE: SILVERCREST YEAR: 2004 SIZE: 44x23'4 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 12/6/2005. CALL IN FOR LK,REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. etbacks ooting (CONTINUOUS FOOTING SLAB r PADS USED): oX //.5/05 Stormwater FINAL Approval: Blocking/Plumbing Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: • Final/Skirting/Vents/Porches/Steps: r/L LI1 HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED 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 • • SPECIAL CONDITIONS CASE # 1.) The application was reviewed by the Jefferson County Department of Community Development staff on September 30, 2004 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: Level I Landslide Hazard Areas and Susceptible Aquifer Recharge Areas. 2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 5.) Buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 6.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis), Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar (Thuja Plicata), and Western Hemlock (Tsuga Heterophylla). Among native tree species which may be used includes: Vine Maple (Acer Circinatum), Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa), Bitter Cherry(Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara (Rhamnus Purshiana), Pacific Willow(Saliz Lasiandra), and Scouler's Willow (Saliz Scouleriana). Among the native shrub species which may be used are: Sevice-Berry(Amalanchier Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark (Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry (Sambucus Racemosa), Snowberry(Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium). 7.) 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. 8.) 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. 9.) 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." 10.) All construction activities shall not encroach upon the buffer. This includes the storage or preparation of materials. 11.) 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. 12.) Critical Aquifer Recharge Areesmay require special protection measures 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. 13.) The applicant is proposing to create or add 2800 square feet of impervious surface and 10000 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Stormwater Management Manual for Western Washington. 14.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(1)(b)(i). 15.) The revised site plan as submitted on December 2, 2004 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated December 3, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 16.) This approval is for a manufactured home installation and a detached garage only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 18.) 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). 19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 20.) The building height is not to exceed 35 feet. 21.) Minimum setback from Totem Ridge Rd right-of-way is 20 ft. Minimum side and rear setbacks are 5 ft. Environmentally Sensitive Areas further impact setbacks. 22.) This parcel has been designated as Rural Residential 1:20 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 23.) A septic permit (SEP04-00261)was approved on November 15, 2004 for a system of 360 gallons per day. 24.) Totem Ridge Rd (P530) is a private road. The road approach is existing and an address of 564 Totem Ridge Rd has been assigned to the parcel. 25.) This parcel was created through W.E. Seton Short Plat subdivision under AFN 417696, filed of record December 29, 1998 in Volume 4 of Short Plats, page 91-94 with Jefferson County Auditor's office. 26.) A minimum of two (2)on-site parking spaces are required for the manufactured home. 27.) 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. 3UILDING PERMIT APPLIC N Review Type: I Jefferson County Department of Community Development MLA04-00553 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00586 Received Date: 9/20/2004 SITE ADDRESS: (,.) CTOTEM RIDGE RD PORT HADLOCK, 98339 OWNER: HARVEY WINDLE PHONE: (360) 732-0348 SUSAN WINDLE PO BOX 1482 PORT HADLOCK WA 98339 SUBDIVISION: W E SETON SHORT PLAT Block: Lot: 3 PARCEL NUMBER: 901114024 Section: 11 Township: 29 N Range: 01 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW MAN HOME TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 37,600.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: PUD PARCEL TAGS: YES _NO_ BEDROOMS: BATHROOMS: STORMWATER: YES_ NO _AREA _ Exist: Exist: Wetland_ Erosion Prop: 3 Prop: 2 Seismic _ Streams Total: 3 Total: 2 Flood Way _ Floodplain Routing �'� /o?/I Date: // F&W Landslide o9- Shoreline _Aquifer 1 Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $154.00 MZL 09/20/04 67704 APPROVED Potable Water Application $52.00 MZL 09/20/04 67704 Total: $206.00 DEC - 6 2004 Jefferson County Plan 41,5W Dpartm aeo CFFERSON COUNTY ASSESSOR JACK WESTERION II \ + I ? r FFERSON COUNTY COURTHOUSE ASSESSOR f )I _ t PO BOX 1220,PORT TOWNSEND WA 98368 E i (360) 385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME / MAILING ADDRESS: : _ :rT Cr C ti t , t. / / TH/S/S NOT A TAX STATEMENT !1 NAME: A- 3i The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the ADDRESS: O ( O( I 1 2_ previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already R sa c—c (...-iG ( LOA `I13 3 3 on the tax rolls in Jefferson County_or if it has been moved to TELEPHONE NO: 3 (a C this county from another area. Please see reverse side for . 2 0 3 qi additional information. 1) MOBILE HOME DATA: (A) MAKE Si L-..YC,k. -la- 5 T (B) MODEL 5 y1/ 'J' (C) YEAR D�I (D) LENGTH 7 (E) WIDTH �31`� (F)SERIAL NUMBER (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) 4 3 7I eel On (H) PURCHASE DATE `( 7(O'{ 2) PREVIOUS OWNER / LOCATION OF MOBILE HOME: (A) FROM WHOM DID YOU PURCHASE MOBILE Cif Ks 14 / ,u c,7-c HO1.4G, ADDRESS S E (c I -P.yA1 t 12,0 fk t E_c-TO 1. L LOA 1 '2) 42)"I (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES 10)(IF NO,WHAT COUNTY? t•-t6 Lt.) IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE? 3) WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES NO (B) IF LOCATED IN A MOBILE HOME PARK: NAME 8t ADDRESS OF PARK SPACE NO. (C) IF NOT LOCATED IN A MOBILE HOME PARK: NAME OF LAND OWNER: lift% Vc ( i t•-1 p 4- LOCATION (ADDRESS) A P (T f-C REAL PROPERTY PARCEL NUMBER/DESCRIPTION h C T 3 SE•�--Z 90 I ( tk4 THANK YOU FOR YOUR HELP! SIGNATURE KELU LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. ' • c'�7�T • • ����V�Y LL & JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 j 360/379-4450 •360/379-4451 Fax `�t1N0 http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# I -4' ._: PROJECT/APPLICANT NAME f/f v �/ r i--r, [.ram „C 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. Te, i.- A i7 r u Hr�c�t � % tFt( C•= leAS, /1itt� �b15/[c_ dANA ( -l'cfre.`, tj fi citArfc I ( (oS Re P E-N if r 7e-1e Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. "l h/ H 14 OS re -/ { i-sa ttW -e+ (c i (`/ t_t''i'c 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. • //E fs ,' 15 /' i r? c� ` ,� �-t ?C E-d .fir',;�,2 ,i d?f�/=�r�-� Ace T T t i 4. Describe the existing soils. Indicate soil type on the site map. l7<(`-/ /ct-/.4 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 acreage of each. /t.c. 57's-icv c�I il t:, ( a- i t✓i / /---c /1-kf 6. Describe any excess levels of noise generated by the proposed use or activity: / ' j/! 12 .—. Co.i�t'�r 2�� /r� � >!" , o APR., iy-c o<<<G— STORMWATER PLAN DEC - 3 2004 stormwater site plan template-rev.10/1/2003 5 JEFFERSON COUNTY DEPT.OF C EVF P11QEN SIGNATURE: ro • • 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. - [r { /1 ,, .'s 11 1 ,Li., , i- , (-#a.K.t 7 ( .C !i 3 j?-./ t-'i+ - ,� <' O L '-( A Ac_c ? y C4— 4ac- f—i 1l t; %� l C. tS(" e i K,t� f -t r c 7 r r \(.i i' t A(_ �1'/ 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.). I: .i 1+- I lbcC— ���.-�t �l(i (/ L f Ae,2Ll •C S t/`( 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. g. 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 proposed facilities from existing facilities. f7 r-(S t_ c l3 i h it < e t4TC.1 c2-a- f i i�c t1 t ')i t> iZ c‘):t� 1�t-c.-t i-e `[-( O 1-1 (ei.( _S t1 w-t J v` c 1 (- 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.] • 11. Describe the performance goals and standards applicable to the project. / /< Ph? CA.) /Efie3 k/G e ( ( t iL!A- rc /2 t 1 L t r F-&-e S ft!_r t T j> : )is i (>_r_:"›„E) f�,% �� ` . _ 12. Describe the flow control system.• A ; � 5 stormwater site plan templates-rev.1 Qr12003 - g •1110 b. Description of special requirements for working in or near environmentally sensitive areas. lU i`i 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). T To L-r_I i Lam( �c_0 C r J! rE:: i(_C t s 4 C_ ( i t r cE i l-i H t hl 5. Construction Phasing. a. Construction sequence Sc=7 Ftotsit-c j",7e Ft—t= (=il'1-1 t:.-- 6r•17 d*(23 14(�� r'r E,'i2-) b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). Provide a proposed construction schedule. SCriF 4.4(LHf2c al f~C-i l �C'!z'rl it / t!C .f? (3 �r�i t `tC:..) 4 -+ " a -cr Sc r' t"/ 1�r L 6ArtA L- f /if it_) i2�Slt&i.: II. Wet Season Construction Activities. S A a. Proposed wet season construction activities. (-) - 1 E- PA'3 f 1 L--- - // E1 C_ C,,- M 6( - b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. /7/,-I-i2 cif; ( (-0(cif e ,4//4 b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. /444-/A 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. c. Waterways. d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.10/1/2003 10 t • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 9. Control Pollutants. lki� r 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). (.-1..31 tp%_- l? Lit 13 r ;cl ii r 1: tLi,4%CJ /-w4 a F , s r- t._'( c �llt-ir�� fc,Iit_ e" r c '( A S c-- 6 t(�ti-t om( t_v 12. Manage the Project. 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). PR t Teo#v AO-.I A c t t— T-t O T 2 u c_ Cal Iki t l _�(� cTr roc b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. stormwater site plan template—rev.10/1/2003 9 • 1 1 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. /) /11-+1 it M c3 t c:.�47? /) 2. Establish Construction Access. 3. Control Flow Rates. 1Lr P� y Sa ,c_ Ai-Jis) Lt` Sto Pr 5 C,�S1rer t=c.,a /LL'4 4. Install Sediment Controls. r� F, i i.-L=N4 t.-e` _ 5. Stabilize Soils. 7f=5e-(rT 6. Protect Slopes. 7. Protect Drain Inlets. tl,2:,-} stormwater site plan template-rev.10W1/2003 8 r . • 13. Describe the water quality system. - (? , tip , 14. Describe the conveyance system analysis and design. 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. lqc / I ( ( (' 0�� c- (� 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. FL i (_ 1, i frt L C.kz ,`-. o iC- //. reo f-E 4 r` rt4 r [^1�! 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. r 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. / 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. stormwater site plan template-rev.10/1/2003 7 1 4110 • approved Stormwater Site Plan,the proposed revisions be S If ormwag wishes Plan mChangeschangespages that c all proposed changes,o shall be submitted te todesigner DCD prior to make or revisions to the originally includesubstitute i thins and include all the reasonosed for the revised to showing y u ural changestion., The submittal information thaexp ange. drawings any structural changes,and any Final Corrected Plan Submittal treatment facilities,flow control facilities, structural("as-built?)s when control ntof BMPs the applicant shall submit a final corrected p If the project included construction of conveyance systems, is (not ple ed.standa Theseon-site hould t management 9 drawings)(stamped by a licensed civil engineer) that accurately represent the project as completed. should beengineering constructed. APPLICANT SIGNATURE applicant/owner attest that the information provided herein is and consente and of all By signing the Construction SWPPP worksheet, I as the asp correct to the best of my knowledge. I also certify that this application is being made with the full knowledge owners of he affected property. { C A 1 �i ......-� ",..�.......(:AN*o NE^OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: a \ kt ti Y. ?I.Usk'' '_-� - 12 stormwater site plan template—rev.10/12003 ,?1,1N6, S011T C r I - f I � ' JEFFERSOUNTY4' DEPARTMENT OF COMMUNITY DEVELOPMENT I '� SEP 2 0 l 621 Sheridan Street • Port Townsend •Washington 98368 ,,,, 360/379-4450 • 360/379-4451 Fax P Is, .0 www.co.jefferson_wa.us/commdevelopment - hrING Master Permit Application MLA: U V Project Description(include separate sheets as necessary): f_,t L' i 0D.(t i Flo t&-C N a k L= c'14 10, 5 2 A C- t-1 J e.tc 4 I-( o r Kbat r�g Ot t'=o O<r To E.r; 1,(✓F i i--1,u r S T V k-13 c-(.) , Tax Parcel Property Number: q C) 11 1`1 0 21 Size: 1 0 i �� 1 (acre square feet) Site Address and/or Directions to Property: ��k?���� t.l' y j o L� I-€ -� Property Owner(s)of Record: /IA(zvC'( Afji> ct55 /a+-t Stk� LL` -lam 2 Tel- 0 1a ��ut1 Telephone: 3( © 1-3 2. o S``(46 Fax: email:Fr)R..� i C i-k S Oal r tc.1"A r fL Mailing Address: —, 0 , r 0 i-(a z -Pe~"1- l-k A.P z a(..f< I LJ r• 5i3 _ 1 , r icr i Applicant/Agent(if different from owner): Telephone: - Fax: X email: X Mailing Address: What kind of Permit?(Check each box that applies) ❑ Building 0 Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** ❑Single Family 0 Discretionary"D"or Unnamed Use Classification ❑garage Attached/Detached 0 Special Use(Essential Public Facilities)** anufactured Home 0 Boundary Line Adjustment ❑Modular 0 Short Plat** 0 Commercial* 0 Binding Site Plan** ❑Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** 0 Propane 0 Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment 0 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 5 GL f- to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE IA' "1----- Date: 512(.0 (o`-{ 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 attorney'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 access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any r ' d later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: ��— Date: 9/2 ca /6 f 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"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if y are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transf e responsibility for adhering to and complying with the ESA. The Applicant has read this disci imer and signs and dates it below. Signature: 7 '"-` Date: e 2 ,/bK G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc r . OWNER BUILDER STATEMENT ;, r y r r 3 ;;_'� t E i The signer of this stat ment does hereby certify that they are the Owners of the parcel referenced herein,that tire) ai• notlicensed confrac�ors-and that 1 they will be assu the responsibility of the General Contractor for the proposed project. 4 i r Signature: U �� Date: ,.:L (c (0 Li ; ^r- 2 0 2004. I GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX. C->E---L S 0- A A I-x"..s ( t3CC qtt o q Li 1`til C( b) til-s- e-t MAILING ADDRESS: U c> S tNL LTDai(0A, EMAIL: CONTRACTOR'S LICENSE Cf 3S 134 WAINS NUMBER: NUMBER (A.-) N. I kt ' i'-( 0 ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New m ood Existing: - ❑ Sewer ❑ Addition Cil Steel Proposed: 7- Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: .,� Height: [Individual System ❑ Repair ❑ Masonry T SEP Permit# ❑ Demolition CI Other: Bedrooms: Water Supply: MO R I`E: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: ❑'Public Et_c:L-T"12 l(- Total: .3 Name of System:?,L.b#1 or ,.) -t-tciZ`.mac"N CC 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: r IBC Type of construction: X" 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 f_] 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 Officel?seOnly Current Proposed Amount Main Floor Consistency Review: m4ti . 2Nu Floor Base fee: 1, 3f0 Floor Additional Section: Mezzanine: / Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement / Pot Water Review fee: it: ' T Other Unheated 911/RdApproach fee: l � ��_ am` Garage/Carport TOTAL: $ ii 1 Decks Receipt Number: 61 I Other / Cash/Check Number: ESTIMATED COST(REQUIRED)t Dates ". •Fair market value of all labor and materials foundation to finish Initials: 2.5_,.... G:\PcrmitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc '''''''' , • _• I. • e..... rrit = �cl ca ! • = 1 • •••1 • ‘ '1 . 74 to 4,(4-- l q 1 o . ..D .. T. 7'`.. 0 .... .... . .. ... . .... cam C7 -4. / (r /1 N - C, s sIffil i � � li ; )4.2 o 4-- r:. - .. . ._ 1 r: ' G910:„ c7c•o d3:,° (1) -cia Z , 2 ( ---..j) , nt ° t _sl, t .,..v) t, ./... — JC v ca r lr) . -. 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