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HomeMy WebLinkAboutBLD2004-00656 ItUILDING PERMIT APPLICAtON MRLA04N00p603 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00656 Received Date: 10/18/2004 SITE ADDRESS: 3663 WEST VALLEY RD CHIMACUM, 98325 OWNER: STEPHEN GRIMES PHONE: (253) 225-8080 DIANE GRIMES 14113 MADRONA RD SW PORT ORCHARD WA 98367 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 901342003 Section: 34 Township: 29 N Range: 01 W CONTRACTOR: TERHUNE CUSTOM HOMES INC PHONE: 360-697-7000 PO BOX 97 POULSBO WA 98370 Contractor's License TERHUCH984MA Expires 07/01/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE, DECK, CARPORT ALSO PROPANE TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,151 VALUATION 240,293.00 ADD'L: 1,246 HEAT TYPE: PRO CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: CONST TYPE: 5N OTHER: 452 SHORELINE: CONST TYPE: GARAGE: 585 SETBACK: DECK: 186 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: Exist: Wetland Erosion Prop: 3 Prop: 3 Seismic Streams Total: 3 Total: 3 Flood Way Floodplain Routing Date: j F&W Landslide o(� Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,783.35 KAS 10/18/04 68551 Plan Check $1,159.18 KAS 10/18/04 68551 State Building Code $4.50 KAS 10/18/04 68551 Potable Water Application $52.00 KAS 10/18/04 68551 Total: $2,999.03 PUILDING PERMIT APPLICAT N MLA04-00603 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00656 Received Date: 10/18/2004 SITE ADDRESS: 3663 WEST VALLEY RD CHIMACUM, 98325 OWNER: STEPHEN GRIMES PHONE: (253) 225-8080 DIANE GRIMES 14113 MADRONA RD SW PORT ORCHARD WA 98367 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 901342003 Section: 34 Township: 29 N Range: 01 W CONTRACTOR: TERHUNE CUSTOM HOMES INC PHONE: 360-697-7000 PO BOX 97 POULSBO WA 98370 Contractor's License TERHUCH984MA Expires 07/01/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE, DECK, CARPORT ALSO PROPANE TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,151 VALUATION 240,293.00 ADD'L: 1,246 HEAT TYPE: PRO CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: CONST TYPE: 5N OTHER: 452 SHORELINE: CONST TYPE: GARAGE: 585 SETBACK: DECK: 186 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: Exist: Wetland Erosion Prop: 3 Prop: 3 Seismic Streams Total: 3 Total: 3 Flood Way Floodplain Routing Date: F&W Landslide ��� 0 p 9Ln� Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,783.35 KAS 10/18/04 68551 Plan Check $1,159.18 KAS 10/18/04 68551 State Building Code $4.50 KAS 10/18/04 68551 Potable Water Application $52.00 KAS 10/18/04 68551 Total: $2,999.03 • • WEST VALLEY ROAD r. 31T-f— -sue 1 Q � cs -I QRAIHY =x Z �QQ c� OR Allyp D I I N a „A..,chi N N X m \ �i �. 1 chi) \ z mtr SAY `\ PImo71 ,A o� � o 4 J1 1 1 m if O y —.a 0 1 f P i 125'+- % 3T-0" 115'+- #. / a,.. 1 / r7. Qglifia(n8 (n —. ______ -- i- .7.rAz 2:1 m i c. ➢ Q p t _ '<1.3 N 6Dam V' 1 I I _i_i_ _ 330'+— 'd LSL '°N sawoH wo}sn3 aunyaal AVSl :6 tiaoz .06 'PO V ik 08/30/2004 15:10 36037 1 JEFF CO DCD • PAGE 01/01 An. 2). 2004 10:48AM 1lr6une Custom Homes No. .4868 P. 2 _• Jame sty LIt V$Camay Mime El Me,Met Pict TIMM WA WI Mill MAIM .o .. ? rtmt 4pIn Balding Type+ Project Typc Frame Type: rteF ••.4 y.1oNew . Wood . ge /Demand OCT 1 8 20( ° °°° 0 Steel .., 0 Alte atlan/Remodel 0 Cotaae o commercial o Repair a Malotuy o Multi-fauady/#o£uaits d Demolition 0 Othei ❑ Indasttial CI °that Bathrooms Bedrooms: Tape of Sewage bhzposab• Type o&Haab Choosy e Eainiar. Pxistinir f 1:7 Sower 0 Community System D Elxc»ciq 0 Or1 Proposed k Proposed: in w7,,,kmie. QTST Totat Tool _ Ifof sewer,fill out the following: ❑ Conventional 0 Ahrmauve ❑ Other 1----- Permic# 3>3P v`j—i Cr Water Supply: .304 a Private well 0 Two Patty Wcll❑ Public Name of water system: Square Footage: Office Use - For Office Use Only /1 Main Floor 1 t�j ( i O.. .1 b.l. 1� Consistency Review `'1 og ..._ 2tia Floor 12L la ' 11 1, (0-12..c% Base fee 1 i'8 3 3.1 Floor Flan Check fee i k• 18 ' • 50 Htd Basement ,_ State Surchuge£ea �,"9 Unhtd Basement Subtotal ( 2 ►c9 5.0 3 Otttape/Carport 5 S l3 r-188.4 Pot Water Review g Desks �� 38,1 911/Rd Approach fee aq(t3},tl Commercial TOTAL C p ea Industrial Receipt# 6KZ5( Other �-i. Cash/check# • 4090 a,q�r a°011 Initials P Date • to j c p4- Estimated Cost; /IIp ,00/L r If within 200'of the Shoreline, Distance to Bank or Ordinary High Water Mark ft.Bank Height _ ft. B1 omsrasdgaoian ogf th e amaapepediecs efrccmde. eep apv}oia8cnata/twetttoaraco sdesupe the to be ampptillondi.deeaoa bet is e ,reiste Jr a pooabtogthesu fDe nof taaie knowledge. mood Heebooti°r up I loather agree to ssoe,indemnify and hold hamlets Jeferaon County against as liabilities,jndgaicrus,court coats,maaooabk awroefa fcca and expawca Which may iq any wy aotsu agaOuJclfrtaon Comfy as a rends of or is ooasegocatac of the gaaroogof this pram& I fiatha aims to provide aces and tut of cat7 co JeSten n Cousin,and MI.mpiny* sporen+i..s or vase the oho purpose et application arylaar and any required hope aspcc n. Agee a aad Ott of may io or mucaae idol be retreated and clan=or dutiogseem bat bow, Signature .Rate: U--aLi--OLI THY h tAne. t0vvl-HD(Niles OVER ► G:\PemmitCentr APORMS\BLDG FORMS\BIDPecmit App&attion.doc 01/08/2004 1 I .• • • ' ON �� JEFFERSON COUNTY r1� DEPARTMENT OF COMMUNITY DEVELOPMENT�- 621 Sheridan Street • Port Townsend •Washington 98368 A.$ �O 360/379-4450.360/379-4451 Fax "�t�C` http://www.co.jefferson.wa.us/commdevelopment/ Stormwater Calculation Worksheet MLA# PROJECT/APPLICANT NAME: C l M e DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as"small,""medium,"or"large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan,if required.. PARCEL SIZE(I.E.,SITE) Size of parcel3. 0' acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet L 3 3)Z31 3-SP sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species,other than noxious weeds,that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir,western hemlock,western red cedar,alder,big-leaf maple,and vine maple;shrubs such as willow,elderberry,salmonberry, and salal;herbaceous plants such as sword fern,foam flower,and fireweed. LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared,graded,filled, Answer the following two questions related to excavated,and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: ZS�S Does the project convert 3/i acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? ,P00 Drainfield,septic tank,etc. sq/ft Circle: Yes No Well,utilities,etc. 2-00 sq/ft Does the project convert 2'/z acres or more of Z3SU native vegetation to pasture? Driveway,parking,etc. sq/ft ' I Circle: Yes /No Lawn,landscaping,etc. `�(�� sq/ft Other compacted surface,etc. /- sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 1 O 2/4 -F sq/ft Cut — Fill (cu/yd) [over] stormwater talc worksheet—REV.10/1/2003 1 • • . impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, clud ,but areeedsott limiteden toriaiof tops, walkways, patios,driveways,parking lots or storage areas,concrete or asphalt paving,gravel and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater. STORMWATER CALULATIONS-1 RV16U3 SURFACE • _ -a _ NEW EXISTING Structures(all roof area) 2.-SclC� so Structures(all roof area) - sclift Sidewalks '-D 0 sq/ft Sidewalks s Patios sq/ft Patios sqfit /, Solid Decks sq/tt Solid Decks sclift (without infiltration below) (without infiltration below) i Driveway 2-F-) C, sot Driveway Other sq/ft Other Total New ut 0aS sq/ft Total Existing tglift TOTAL NEW+TOTAL EXISTING` t--a at C sniff 'This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v.REDEVELOPMENT Divide the total existing impervious surface above by the of e parcel and convert to a percentage: Does the site have 35%or more of exdstlna imper<Jriou su Circle: Yes No yes, proposalis considered redevelopment and the attached Figure 2 should be FURTHER INSTRUCTIONS: If the answer is the �����new development and the used to determine the applicable Minimum Requirements. If the answer is no,the proposalthe attached Figure 1 should be used. At this juncture,the applicant should referclassification ofhe f the projectleFlow and the Chart to deapplitermine require nimum mr Requirements for stowater management. DCD staff will help verify the For proponents of "smalr projects who must comply only with Minimum Requirement #2---Construc ion Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices(BMPs) Packet Proponents of"medium"ent meet all tOroje�ousee that must meet only Minimum Requirements #1 through #5—and for large" projects—those must a Stet 1 r Site Plan, m Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual APPLICANT SIGNATURE By signing the Stormwater Calculation 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. 1 a 2 RA . &t k \ q (uwOOWNERoR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) 2 stonT,w IC I(cs wor sheet—REV.10/12003 • • g, t?N t~O 44 JEFFERSON COUNTY # - 1 DEPARTMENT OF COMMUNITY DEVELOPMENT ' OCT 1 0 2004 621 Sheridan Street • Port Townsend • Washington 98368 ' O'' 360/379-4450 • 360/379-4451 Fax G` http://www.co.jefferson.wa.us/commdevelopment/ - STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# PROJECT/APPLICANT NAME: r,I(y 1 S 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. / log k,r. ..-5 1 ' ipLavial7 1 -121)/- z'ice ._a.,s-/ oinvethiczi Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. do L02.0.4 t - ,Zie tea-PPirti , 5thilib— d r" Vta csi ro vt�1 oriel, y2fr 1 3. Desc a the e 4stinev getation. Indicate n e vegetation areas on the site�m'ta�p� . prr/ rl .situ 1 r'y v L. z S /�EYi itete_ r r`e- 4- c prn , 5 i Ike_ 1/� �_ � ' �(i e ' 1Yl° 5 et �Ult� DS - 1� 0 id4/l i r 4. Describe the existing soils. Indicate sgil a on the site map. l 1 'e,.',,e . ) Q Un� 6.011 (-() (4I r& i-A" ' /1 /L0.Qf c4 t 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. j) yati I,c eakt. twArbrom 414e )5t +CQF tTit W ' i 1,6 1v O i CSx-cH�b oL yr!_a..�n ar .. .14 eth el ell-el 'OY Z . aizt d i I 6. Describe any excess levels of noise generated by the proposed use or activity: (. I1F' storrnwater site plan template—rev.11V112003 5 • • 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,wetlands,lakes,steep slopes,etc.). 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. CX v jA.) , A Q i , O nuu-- • 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. 12. Describe the flow control system. OCT 1 $ LJL`+ Iv ( � etarmv tarsteplanterpate—rev.1011200? 6 • 13. Describe the water quality system. N (A 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. CC.Arla r\_D Jp r 4- 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. 0CtP -x' .. cv 1r\cL t_ 18. Describe methods for restoration of the site. vo�ss 54 noch_U e. v-ee e-k- d rl 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. • 1 v 7A 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. • //1-\ storrnwater site plan template—rev.10/1/2003 7 • S 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. .� p< « eQ 2. Establish Construction Access. v a�\l e\ J1h eJL -- � scLr�� ►r��-�- cAt 3. Control Flow C/Qlt 4. Install Sediment Controls. 1J/A dJ j J Q 5. Stabilize Soils. 6. Protect Slopes. s� L� *CAA.e� ► u.A fted , Y. Lk) CArl S4c t 1 7. Protect Drain Inlets. ►�/� r )w OCT 18 -2c94 8 stc;nvatar sita plan tenlata-rev.1 0.W12CC3 • s 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 1 .131) 9. Control Pollutants. . NYIA LLCLQ . 10. Control De-Watering (the act of pumping groundwater or stormwater away from an active construction site). K)/M, cl.nj,l`. . 11. Maintain Best Management Practices(BMPs). )r10.i a CSY cs\n SCS I 12. Manage the Project. �- (al 2stc_peJlA s\ At.�c al\ , 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.10/12003 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). N/A 5. Construction Phasing. a. Construction sequence • Q c C t &y-� CAA , nr�c �.l , 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 construc activities. b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the properowner 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 1 8 , 4 r)' stormwater site plan template—rev.10112003 ( _(Li s`,N couNiy' 10 1N1 DLI'1. OF COCOM ;UNITi' OEVELOPt� S 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. • UYL -i ) .l /0 /1/c 5/ (DOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 12 stormwater site plan template—rev.10/1/2003 v • T3 rC (, i t . OiVCd II �I ' , `. I JEFFERSON COUNTY �) • I \,„-, DEPARTMENT OF COMMUNITY DEVELOPMENT L ( OCT 8 2004 I L. �, .� 621 Sheridan Street• Port Townsend•Washington 98368 Neils 019 360/379-4450.800/831-2678.360/379-4451 Fax PErl. Of ( u P,)') www.co.jefferson.wa.us/commdevelopment Master Land Use Permit Application Form44L-4-604115172... PROPERTY INFORMATION M�• 64-*"' ©3 Tax Parcel Number. El 1J ElE El III On El R Subdivision Name: Lot Number: Property Size: . - 0(0 CISiv square feet) Existing Use of Property: V( O aV\ Site Address and/or Directions to Property: 3(003 l u . \.)CU 1.__e_ 1 Rd G(A.t vrAe.L1.4,-1 I L...i0. APPLICANT&OWNER INFORMATR LONG flne 67 r L rA e.s > Applicant(if applicable): _.ipl/1.� V V Y2-i. --S Telepho�n`e' c 2' —30 2 C Address: ILA ( I -3 YYk.OLA,Y O IA.OV ! l , S -A.- City:ThY t CV G.,(/L(,L.J`(\ Stater• Zip Code:G.� (O`7 Email Address Applicant's Signature:. A,0 D n r-C._ '-,�'�pv1L 1 Property Owner(s)of Record: `-�CC2 ) yL..Q :/ Telephone: Address: City: State: Zip Code: Email Address I acknowledge that the applicant above is applying for a building permit on my property. Owner's Signature: I hereby designate to act as my agent in matters relating to this application for permit(s). Agent's Contact Telephone: Address: (PROPERTY OWNER SIGNATURE) (DATE) DESCRIP QNNOF PROPOSED/' t USE OR A/ACTIVITY(include separate sheets as necessary) 1Y [THIS SECTION FOR OFFICE USE ONLY] Refer to the specific sections of the UDC referenced below for more information and further requirements. An asterisk(*) indicates that a supplemental application or questionnaire may be required. Type I Permits Refer to: ❑ Septic Permit/Evaluation of Existing System(EES) UDC Section 6.4.1 and Chapter 8.15 JCC ❑ Building/Demolition Permit UDC Section 3.2.1 and Table 3-1 ❑ Allowed"Yes"Use Consistency Analysis UDC Section 3.2.1 and Table 3-1 ❑ Home Business Table 3-1 and UDC Section 4.20 0 Stormwater Management* UDC Section 6.7 ❑ Road Access* UDC Section 6.8 ❑ Boundary Line Adjustment* UDC Section 7.2 ❑ Minor PRRD Amendments UDC Section 3.6.13.15 ❑ Sign Permit* UDC Section 6.15 ❑ Site Plan Approval Advance Determination(SPAAD) UDC Section 8.7 ❑ Shoreline Master Program Exemption/Permit Revisions UDC Section 5 ❑ Temporary Use(based on use may be Type II or Type III)* UDC Sections 4.38 and 4.39 (OVER) MASTER LAND USE PERMrr.DOC REV.11/182003 • lbw Type II Permits Refer to: III❑ Discretionary"D"or Unnamed Use Classification UDC Sections 3.2.1, 3.2.2 and Table 3-1 ❑ Cottage Industry UDC Section 7.3 and Table 3-1 ❑ Short Plat, Preliminary and Final* UDC Section 7.3 0, ❑ Binding Site Plan* UDC Section 7.5 ❑ Conditional(Administrative)"C(a)"Use UDC Table 3-1 and Section 8.8 , ❑ Conditional(Discretionary)"C(d)" Use UDC Table 3-1 and Section 8.8(Discretionary Permit Review Process Determined by Administrator) ❑ Variance,Minor* UDC Section 8.9 ❑ Wireless Telecommunication Ordinance 06-0712-99(UDC Appendix C) ❑ Shoreline Substantial Development(Primary Use) UDC Section 5 ❑ Forest Practices Act/Release of Six-Year Moratorium for Single- UDC Section 4.16.5(c) : Family Residence ❑ Appeal UDC Section 8.4.2 SEPA 8.10.12(b) Type Ill Permits ❑ Conditional"C"Use UDC Section 8.8 ❑ Long Plat, Preliminary* UDC Section 7.4 ❑ Planned Rural Residential Development Preliminary Approval UDC Section 3.6.13(must be in conjunction with an (PRRD)and Major Amendments* underlying land division application) ❑ Plat Vacation/Alteration UDC Section 7.1.3(d) ❑ Variance,Major* UDC Section 8.9 ❑ Reasonable Economic Use Variance* UDC Section 3.6.4(h) ❑ Wireless Telecommunication Ordinance 06-0712-99 UDC Appendix C ❑ Shoreline Management Substantial Development,Secondary Use* UDC Section 5 ❑ Shoreline Management Conditional Use* UDC Section 5 ❑ Shoreline Management Variance* UDC Section 5 ❑ Appeal UDC Section 8.4.3 SEPA 8.10.12(c) Type IV Permits ❑ Long Plat, Final UDC Section 7.4 ❑ PRRD, Final UDC Section 3.6.13 Type V Permits ❑ Special Use(Essential Public Facilities) UDC Section 3.3.5 -"-, ❑ Jefferson County Comprehensive Plan/UDC/Land Use District Map UDC Section 9 ° ! ; , OCT 1 8 2004 Amendment* I "I L. " ❑ Jefferson County Shoreline Master Program Amendment* UDC Section 5 i ❑ Appeal of SEPA UDC Section 8.10.12(d) • -- - _ _ __ I 17F1. (A °'IM i �� G i ('i;i idl Other Local,State or Federal Permits -- ❑ Please identify any other local, state or federal permits required for this proposal,if known: ACKNOWLEDGEMENTS [PLEASE NOTE THAT TWO SIGNATURES ARE REQUIRED] By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property.Any material falsehood or any omission of a material fact made by the applicant/owner 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 required later inspections. This right of entry shall expire when the County (through the Administrator or the Administrator's representatives)concludes the application has complied with all applicable laws and regulations.Access and right of entry to the ap -cant' pro rty shall be rQe9u�es�ted and shall occur only during regular business hours. 1. k ,( er� ioa,3 o/. PROPERTY OWNER (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 E The Ap 'ea has read thi isclaimer and signs and dates it below. Imo/ 2. - I!0(7(_7 PROPERTY OWNER (DATE) • • WEST VALLEY ROAD - - - N. -7-7 - 315'+— 1 -1Or> X z�'O-/'R/Mq r�'1 oILD Z Iwo RglNA-7, x o I 1 N I - �� 0 1 1 > \ ? 4. • ,e , N /8 \ A% I (Dn \ 11 /"1- h // Z PROPos fD °R� wq Y I b C7LC,�� -I \ mm� cri C�j� / / \ oM� I ' / Ci P o 8 o m N w 0. II CA I - ,,_, -a 0 1 I I- f r r 125'+- 37'-0" ' 115'+- I / / Ilk 1 / \ 1 / / �r-4ornm32T1i'8 (I) N w=°'c°',,-10-0,- — i ...,, _ / / N) �cD pm=r2 -- __ i + oz0AzrZ Pi I �mmcnw rU) <�0O II _ �m N D O I 0 0 - - O K vi o-wm N 1 • • N • OCT-24-2004 05 :59 PM VONNE ELLIOTT 509 253 4611 P. 01 ii1 Steve and LaVonne Grimes 14113 Madrona Rd. S.W. Port Orchard, WA 98367 October 21, 2004 Jefferson County Dear Pete Bonyon, As per on phone call, I am writing to request that Jefferson County stop the permit process on our application, reference number: MLA 04-603. Please refund the fees and paperwork to the above address. The home plans belong to Terhune Custome Homes, you can reach them at (360)697-7000. Thank you for your time and attention to this matter. Sincerely, ó4tla r Steve and LaVonnc Grimes AA a s3-gs 7-4761 , 2b6. Ctuo 31°0 -- 371-..4/i 5! 25