HomeMy WebLinkAboutBLD2004-00645 *BUILDING PERMIT APPLICAPION MR view 00pe590
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00645 Received Date: 10/11/2004
SITE ADDRESS: 'ABOB RD
QUILCENE, 98376
OWNER: WILLIAM NEAL PHONE: (360) 652-8018
ANNA NEAL
1219 188TH ST NE
ARLINGTON WA 98223
SUBDIVISION: Block: Lot: T 18
PARCEL NUMBER: 801 21 201 1 Section: 21 Township: 28 N Range: 01 W
CONTRACTOR: SOUND BUILDING SYSTEMS PHONE: (360)437-1219
3546 THORNDYKE RD
PORT LUDLOW WA 98365-8229
360-437-1218
Contractor's License SOUNDBS027NM Expires 8/19/2006
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI NEW POLE BUILDING
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 0
VALUATION 18,808.00 ADD'L: HEAT TYPE: UH
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: SHORELINE:
CONST TYPE: GARAGE: 1,120 SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PWELL 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_
14h/cv fFp Shoreline _Aquifer _
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: A JD I- OV E F)
Permit $307.25 KAS 10/11/04 67790
Plan Check $199.71 KAS 10/11/04 67790 NOV - 2 2004
State Building Code $4.50 KAS 10/11/04 67790 Jefferson County Planning
Total: $511.46 & Building Department
-Po(Cs_OccXco L..)
• BUILDING PERMIT •
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD04-00645 Received Date 10/11/2004
SITE ADDRESS: 1029 DABOB RD Issue Date 11/2/2004
QUILCENE, 98376
APPLICANT: HAROLD F NEAL PHONE: (360)732-4642
1030 DABOB RD
QUILCENE WA 98376
SUBDIVISION: Block: Lot: T 18
PARCEL NUMBER: 801212011 Section: 21 Township: 28 N Range: 01 W
CONTRACTOR: SOUND BUILDING SYSTEMS PHONE: (360)437-1219
3546 THORN DYKE RD
PORT LUDLOW WA 98365-8229
360-437-1218
Contractor's License: SOUNDBS027NM Expires: 8/19/2006
PROJECT DESCRIPTION: NEW POLE BUILDING
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS:
UFFER: (
Footing: i�:fCor�� _::�J2'/ rT
'/ - I
Foundation:
Stormwater FINAL Approval:
Underground Plumbing:
Underground Insulation:
Shear Wall :
Framing: Ok 3/2 0 5 -65
Plumbing:
Propane Tank/ Lines:
Insulation:
Sheetrock:
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval ��Z���
Final/Occupancy Approval:,)LU
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 FOR CASE BLD04-00645 •
1.) Truss construction documents shall be prepared by a registered design professional and
shall be provided to the building official and approved prior to installation. Truss shop
drawings shall be provided with the shipment of trusses delivered to the job site.
2.) 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.
3.) 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.
4.) 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."
5.) All construction activities shall not encroach upon the landslide hazard area buffer. This
includes the storage or preparation of materials.
6.) 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.
7.) 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.
8.) 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.
9.) A Stormwater Site Plan 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.
10.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
11.) 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).
12.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
13.) The building height is not to exceed 35 feet.
14.) Minimum setback from Dabob Road right-of-way shall be 20 feet. Minimum north and
south property line setbacks shall be 5 feet. Minimum rear(east) property line is abutting
a commercial forest land parcel. Proponent is aware of this and accepts the
consequences of building within the 250 foot commercial forest land buffer.
•
15.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height rom the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
16.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
Couk C-,0 ,
.O cn w N
FL
c` "U C) C 'o DCD m O 0n v r
zrs ,0 00 zo rn MF ZF z 0
m
� A j
5 2m ,- � � r
PERMIT # BDIo_, 0mxv0 o
I � mu) Cv mzm_, Zm
G� cs mo I oo 0 NOo m '
-o a)> Om �mc. mrn9. w 0m 04 - 64 22 5 Nm macov " a�0 0o D � o _ 5
mzEffERSON CO
Z a mZz - I 20 �� COUNTY Dv)
�n �x o� voo �53 " p w
,,,,a Zm 2� Zr rc v N o M D I
z cnn o x,-• z o 0A a as = F c,�
vo in NF T � 'a nJ. () )
Ap m Zp Dm > cn (Q N CI Ili
DOUBLE 2X12 #1 D-F RAFTERS
? CA p >
p N
O F 0 m N N
x
m Dz _< c o
0 C) 7 0
•z N r r I LA
''' o
ma
m
D r
��p�� J/ � DOUBLE TRUSS 1 co
z - rry 0 ��
0\ D
2 .74
o
? . w
W N O
t N , F
0
0
0 DOUBLE TRUSS �
`f A XI — IX
�03 —
v
0
o o D ,w(/)n m
D Z7-PCO,Cal -0
N boz o — N O
m( CSO c
riminim
r m oOW R-
�' O z r ." �.�� o
cn
o z DOUBLE 2X12 #1 D-F RAFTERS
O Dm o m f v !XI DO
N N
o
mv 10X8' OHD 12'X12' OHD
CA(7 D 14'-0" 14'-0°
o cri
iA
C)03
bd o a' 280" vo
v
0 m � _ v_.m.
0 � C r > . n
mo ^ O m�^
'
o nCXmm 1 -I C7 cnmox
-^ mmDcCD —/ • o-I i
o zrz\5 a, r z>-n
' _ u,V mnkXmm 5 2 ' mo
0. L '1%O >. I Dz� °
v �J FivDCd O co- rg DC"
4 1 7)> F Fw
m —
. PERMIT # BLD
04 64 t
.,?,. ON c,4 5 t'
JEFFERSON COON -,
tt r
4i ,.....
4 DEPARTMENT OF COMMU L�QPMENT"� t /�
621 Sheridan Street • Port Townsend •Washington 98368 j' .'
hrr{.oI ritiflJi�)f�it Ut ry 1ollrii ��1
Q 360/379-4450 • 360/379-4451 Fax i..
http://www.co.jefferson.wa.us/com mdevelopm ent/
t' ' _,
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# I-- , t J PROJECT/APPLICANT NAME: , CeV, ,A,a /A 41. / r Ak yam,.
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 0g--c4f t- 772c i--% 04 (filit i4: I `/`%- �/' -cir/
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site m,.
isiCM.: 4-L c D= 4..L "We7", ,, 41;1..%n-(, tAA.2).7A fi•.'L F' ;Y(t/'j` , -I.
•
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
_c.c A::1 'Ic S iL
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
(re:--e's s/ UA,De-a 5rp,4?-1 4.. _ `,r Cr'1,; ls0"Tit--77- /.j '2L•110r?r;:-
)
4. Describe the existing soils. Indicate soil type on the site map.
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 indicaje acreage of each.
A) 1
6. Describe any excess levels of noise generated by the proposed use or activity:
IL P1- APPROVED
STURMWA I'ER PLAN
Storm ater B s NOV - 2 2004
stormwater site plan template—rev.10/1/2003 Required
E.
JEFF SON f
UN Y
DEPT.OF C , 11EVF PME
SIGNATURE
r
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.
8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads,and sensitive/critical areas
(streams, etlands,lakes,steep slopes,etc.).
�' / C +n 9_ LT ./ 19.17r j 1 �-i) 6-4'7) rc. i.t, " 4,..l. f
d 1.' r-/( a i4--4-E- / i`' 4 .�=J
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 t e site plan an differentiate proposed facilities from existing facilities.
•D1/r�%'l tJI' 7n• ✓: ,...-/ ;f:i.4- 'f) rjs4:,--, J 4J_. r ie--z- :) '?c ;� .-�T�.74,,---
N'')C,ti.. Liic-e rLry27L 6,fLAC1 t)"., Ac 0 i %-liii/3i7 ec- S
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 tential for dispersion of contaminants.]
`
n �,y1 y�
G2J IY C..�i' Y- C �-- _ x.�--v--rsz;L.i 1' f 5 .r4-,L,. ,— 0 7. ��ii../4 j�J J�-. i..
je, (i,2 j---, i.,_,.`. f"?i.-s{) -
11. Describe the performance goals and standards applicable to the project.
64..(
12. Describe the flow control system.
i
t CCU ' 2004
stormwater site plan template—rev.10/1/2003 6
PERMIT # g1D-
13. Describe the water quality system.
0 4 - 64 5
. : OM 3 2 200
JEEFERS.O.g CORY BBB
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.
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
` tip :i:, c (/.4 y i . r)s
O`(4..,:4 j Y I" )/4-s71C-
17. Describe the proposed surfacing material.
9Pt.. c'cll S )1 c, F. JSS,r-n Cc!) L (47-- .. /�y/2 uJ 3");-11/2.4%. '�,r ✓0<,)
f. ; rr-t �`.r -4 3 V )1 ,-:i A-t > G• s, %t_ l 't r y i�. -�,t
' l S
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.
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
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.
2. Establish Construction Access.
3. Control Flow Rates.
4. Install Sediment„Oentrois.
C.c., ,s C.C:' 131er .- 1V ii A- i t. ,)
C to To c 4/ ct A, C,
5. Stabilize Soils.
6. Protect Slopes.
7. Protect Drain Inlets.
"I )4
stormwater site plan template—rev.10/1/2003 8
PERMIT # BED
12 Required Elements—Construction SWPPP(continued) 0 4 6 '4.___5
8. Stabilize Channels and Outlets.
K.; 'AJEFEERSON COUNTY ;; 1 2 2004
9. Control Pollutants.
zit ' kt j t!f l 4-(.s rf P ,ib C -)
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
12. Manage the Project.
i J�i°i �%� C1�ryt :irr> '�,; J�° a'�3 t' - j 4-4 r )41:
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
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
•
b. Description of special requirements for working in or near environmentally sensitive areas.
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).
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.
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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.
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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
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 the affected property.
(LANDO NER OR AUTHOtc
EPRESENTATIVE SI TORE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
•
OCT ; 2 2004
12
stormwater site plan template—rev.10/1/2003
��¢SOrr c06. JEFFERSON UNTY
' DEPARTMENT OF COMMUNITY DEVELOPMENT IP
`-4 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379 4451 Fax
440
�q O www.co.jefferson.wa.us/commdevelopment "- i
S`$ING` i; i
i4` i
1'i ' OCT 1 1 2004 ' ` =:
Master Permit Application 1;ML: }
i i
Project Description(include separate sheets as necessary): __._
e - et., - N l lMI re- ... ( r zE cal_
}b i
�.J�c�c{Ar�}�r�f i'"(. elf ( � �����IN, t;t�F r�t:RiE 1;-r
Tax Parcel Property __.... ".__.
Number: cV f " 2 I1 — 0 aSize: 1, ,
7(d�(, (acres/square feet)_
Site Address and/or Directions to Property: , S ,K,,,e}.i, Fr.,M its r✓Ft,A.,fm �/�) �`
��� Lj'�e41 LL 4vH•t�i/I.
Property Owner(s)of Record:
Telephone: Fax: email:
Mailing Address:
Applicant/Agent(if different from owner):
Telephone: Fax:
email:
Mailing Address:
What kind of Permit?(Check each box that applies)
kBuilding ❑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
UkGarage Attach /Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* El 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*"
❑ Stormwater Management 0 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 to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
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 attorneys 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 required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: Date:
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 you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature:
Date:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
411) OWNER BUILDER STATEMENT • •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR-MANUFACTURED HOME INSTALLER: PHONE: FAX:
SoaN/14 TaliL.i1k•a(, ciS3"t j .Z...t. (3,4) ) Y37- 1,it ( )
MAILING ADDRESS: -?s-44 TJ f-!g���i ��, EMAIL:
CONTRACTOR ''
S LICENSE p . Ala be.;;‘,.„ 11Q yti, ,E13(or WAINS
NUMBER: i gC A.t ,-F3.0 r") 7 AJ Al NUMBER
ARCHITECT/ENGINEER: /ILL i LL G f hia....ciA L. PHONE (Fcc)3)cz/yl-i--p 2 FAX: (1(5 ) J y-i7?;,)
MAILING ADDRESS: :i e(y M 4L,i,..r ss_r`• At F. ,]ge..,:i'I ._is_.`77:i,j EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
X New K Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: sie Height: .Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ 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 U 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 ` 43{ �' �' ;f y'�i fir.
6
Current Proposed � ,
Main Floor Consistency Review: x a � `, * '
i,zc.) .603z x r
2Nu Floor :. * ;a te
3 Floor Section: �,�� ��q ''° ��, �` ��
J .. 4IS 'LS 4 i
.r 'z tx .i s,
Mezzanine: Plant ck fee: , �� f j ,, .� 1,y
f� k r a3 - ''Heated Basement States urge fee: �`%'_` .. ",, * r "',
` x a _�R ,n, �r .Y
Unheated Basement Pot Water Rev .f h;- w £• t jti a ' z� , - ' ' k
Other Unheated 911/Rd Approach'fe r •Y i � �; i;{t
4 :' car 7. a ,�
Garage/Carport TOTAL $ C , 1 � >
Decks
tec EO PIUm 'r: �:,r w, caw �, 4
.� fit,
Other '�Cashftheck Number ` f ' � �<
yS
` `oaf j, gg— ' 1"3-.
ESTIMATED COST(REQUIRED) Date: 10
F
•Fair market - - • : - . . = s foundation to finish �o �i../04.3:-
. " H `
/ i 807 6)c) Ini l w,, ,,.., ..,., . - rt ,
G:\PermitCenter _ •• I,•.: S RMS\Master Permit Application 7-8-04.doc
7
-r 6-N. -_ ,,.,....... .,
t 1
141
. �
N_ ` �
,(. r �
•
•• 'I► .r .. 5'. . I
• j •
� �
'
•
:
•
•
•
r '
111 -
.-• ---..._._.- - p . � ;
./ , • G,
� emu, - `�.. >�t` \t • _ __.. 4U
v: I
u •
-
r •
a l,.,
•.
.
•
rj .. . :
12.'Or o�
1 •
__.... -
•
_....-.-.._ ._..... ._. ..... ._. r ti
�r t,,
v
fiiI
:
ek 1 . f• ., i . ' 4 , i
. , ,
• . ___ ___ • • • . . • •• . .. .. •..... .
•
...... •___
k..,,, .
N., .
. • . . .... . ,
w
- f ...- • • •••• .• - • . .
•
•
>
.n
• 3 '
.01
A i -
. �l
Oo i. : i
-N
fi
r : ...P
i.[ T1
i
i
:
r•_:_ _-
C n ./
•
t ,:,j7_• :...,..7. it ,:
• C� p
. • •
C' ....., .
.rZ1 �
1 �� ,* r...�
. , ._........„.
1 -
....-...,..
; . A 2-7 7/ ,
I.--ex,Zs(ma4