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HomeMy WebLinkAboutBLD2004-00704 • MLA04-00634 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00704 Received Date: 11/8/2004 SITE ADDRESS: 4D 14 \\o PORT HADLOCK, 98339 APPLICANT: TODD HARALSON PHONE: (360) 437-7678 472 SENTINAL FIRS RD PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: TX25-i PARCEL NUMBER: 901121008 Section: 12 Township: 29 N Range: 01 W CONTRACTOR/ HORSLEY'S MOBILE HOME SRVC INC PHONE: (253) 841-5696 DEALER: PO BOX764 PUYALLUP WA 98371 Contractor's License HORSLMH074DC Expires 3/18/2006 INSTALLER: HORSLEY'S MOBILE HOME SRVC INC HORSLMH074DC 3/18/2006 (253) 841-5696 PO BOX764 PUYALLUP WA 98371 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MH TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: SILVERCREST SETBACK: VALUATION 46,070 00 YEAR: 2005 LABOR & INDUSTRIES APPROVAL? SIZE: 44X28 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO STORMWATER: YES NO Exist: Exist: AREA Plat Conditions Prop: 2 Prop: 2 Wetland Erosion Total: 2 Total: 2 Seismic Streams Flood Way Floodplain Routing Date: I F&W Landslide � iD 1 0 4 (C4)-j` Shoreline Aquifer Type Amount Paid By: Date: Receipt: AR E10eV ED Permit $154.00 BAC 11/08/04 68677 DEC - 8 2004 Potable Water Application $52.00 BAC 11/08/04 68677 Total: $206.00 Jefferson County Planning Gol& Building Department • • 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#: BLD04-00704 Received Date: 11/8/2004 SITE ADDRESS: 110 CEDAR LN Issue Date: PORT HADLOCK, 98339 12/8/2004 APPLICANT: TODD HARALSON 472 SENTINAL FIRS RD PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: TX25 PARCEL#: 901121008 Section: 12 Township: 29 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: HORSLEY'S MOBILE HOME- 74DC Expires: 3/18/200E PO BOX764 PUYALLUP WA 98371 PROJECT DESCRIPTION: NEW MH MAKE: SILVERCREST YEAR: 2005 SIZE: 44X28 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 12/8/2005. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED):/Z .0-0y Stormwater FINAL Approval: Blocking/Plumbing::,--c. ut i1 ,,A YCPropane Tank/Lines ......--- Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: OK -der +/,rls.Ll II/7/i;C /,/' 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 FFERSON COUNTY ASSESSOR JACK WESTERN III FFERSON COUNTY COURTHOUSE ASSESSOR PO BOX 1220,PORT TOWNSEND WA 98368 (360) 385-9105 MOBILOME INFORMATION FORM OWNER'S NAME / MAILING ADDRESS: Tr _ THIS IS NOT A TAX STATEMENT �Di9r/ t Sui INAME: The purpose of this questionnaire is to obtain information ADDRESS: �� `�;/�Jr �;, regardng either the current location of a mobile home or the t L /Z S previous ownership and location of a mobile home. This will e, y-� �: help our office determine whether the mobile home is already ' `f`r i)4 cL. /S 3/ on the tax rolls in Jefferson County or if it has been moved to this county from another area. Please see reverse side for TELEPHONE NO: V °7 - 7 C' 7> addfional information. 1) MOBILE HOME DATA: (A) MAKE _S/L//CAE-/t-S 7-- (B) MODEL DiSL4?E/ti--,Cy (C) YEAR ,;Z:%e� (D) LENGTH VV (E) WIDTH �3 (F)SERIAL NUMBER (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) II V4 074l ,CZ) (H) PURCHASE DATE ie''„2.3 e y 2) PREVIOUS OWNER/ LOCATION OF MOBILE HOME: / I ; i �✓Ii t (A) FROM WHOM DID YOU PURCHASE MOBILE /f_ /(� ,, /1 /j 4 L (--ili /" i'L(2-- ADDRESS fill,l/1-4 LL(/.e C) ei i (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES NO (IF NO,WHAT COUNTY? ) 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: 0 i 4NAME 8t ADDRESS OF PARK 3 T t y Li�` A 1)1 e ;. SPACE NO. (C) IF NOT LOCATED IN A MOBILE HOME PARK: NAME OF LAND OWNER /� h 11) LOCATION(ADDRESS) - REAL PROPERTY PARCEL NUMBER/DESCRIPTION f/d/1-L I![.- 41 lit/ 12. l be 41 , 1 7 / , THANK YOU FOR YOUR HELP! I i I..'' , k' SIGNATURE • 4 004 KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT PF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. NiL SØWE#?1i2E5F • Du' cove Proudly Produced By: New 2004 Features: I •Taped and textured interior •4" tile backsplash in the kitchen & baths 66. cHampion ames-Nardi ® exterior siding 'Steel insulated front & rear doors HOMES OF OREGON • Vinyl Framed Dual Pane Windows •Exterior design with roof gable Floor Plan: Optional Features: 44'-0" 6.5 /FREEZE OPT R ® --••7 .1.. S ------BATI#o UTILITY " OPT DM 0� J I • f _92G1o _z� rLINEV _ - - mit Noma —BAT ' CO1111 � I O `PAN11TRY_ r_Z hJ __-J CV / HALL r LIVING MASTER BEDROOM#2 ROOM BEDROOM 10-11 x 9-2" 16'-8"x 12'-10" 12'-6"x 12'-10" Model 4442R - 1173 Sq. Ft., 28' X 44', 2 Bedroom, 2 Bath All room dimensions are approximate and subject to change. Authorized Retailer: Disclaimer: Champion reserves the right to modify features and specifications, exchange materials, and discontinue features to meet market conditions without prior notice. All specifications and illustrations are subject to change. www.championoregon.com • • SPECIAL CONDITIONS CASE # BLD04-00704 1.) The application was reviewed by the Jefferson County Department of Community Development staff on November 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: coastal SIPZ. 2.) Marine shorelines and islands are susceptible to a condition that is known as seawater intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater suitable for public consumption without significant additional treatment and cost. Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater withdrawals (primarily through wells). The Washington Department of Ecology is the agency with statutory authority to regulate groundwater withdrawal for individual wells in Jefferson County. New development, redevelopment, and land use activities on islands and in close proximity to marine shorelines in particular should be developed in such a manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to the maximum extent possible by infiltrating stormwater runoff so that it recharges the aquifer. 3.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according to the County GIS map. There are voluntary and mandatory measures identified in the Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23, 2002) that apply to well drilling proposals and building permit applications on existing lots of record. A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources within 1000 feet. 4.) 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. 5.) VOLUNTARY MEASURES OF COASTAL &AT 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. 6.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. • lk 7.) MANDATORY MEASURES F COASTAL 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 requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 8.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 9.) The applicant is proposing to create or add 1851 square feet of impervious surface and 2558 square feet of land disturbing activities. 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.) 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). 12.) This approval is for a manufactured home 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. 13.) The site plan as submitted with the manufactured home permit application on November 8, 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 7, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 15.) 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). 16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 17.) The building height is not to exceed 35 feet. 18.) Minimum setback from Oak Street right-of-way shall be 20 feet. Minimum setback from Flagler Road (SR 116) right-of-way shall be 30 feet. Minimum side and rear setbacks shall be 5 feet. If an ESA is present, then the more stricter setback shall apply. 19.) Exterior lighting for residential uses shall not exceed twenty feet (20') in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 20.) 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. 21.) A minimum of two (2) on-site parking spaces shall be provided for the manufactured home. 22.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 23.) A septic permit (SEP04-0220)was issued on October 4, 2004. A road approach permit (RAP04-0286) will be issued with the building permit. 24.) The parcel is served by PUD #1 water. 25.) An address of 110 Cedar Lane, Port Hadlock has been assigned to the lot. Cedar Lane is a county local access road (C655009). Flagler Road is a state major collector road. MANUFACTURED HOME-FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 SILVR 44 X 27 11830546AB 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE EM VAL FROM L PR ERT . Signature of Legal Owner and Title,IF APPLICABLE < Signature of Ai�jgp�jgal Owner and Title,IF APPLICABLE NOT• YSEtad NT/SA riidjl NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE '.gStON g�� ��Fkp3,•.,. tale of Washington 1. Signed or attested IZA ft10TAq t S. County of -1t k(-! before me on 11 17- (...c* Y b� �+j �(�. .1 •Y Signature '"H r PRINT NAME OF LEGAL OWNER • 14, pU L��• I 'NOT RY OR AGENT �> 3 3, PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY sssi1Op/WASH'�`���` Title `, County/Office No.OR -� ,Ay, AND: Dealer No.OR - DEALERSHIP POSITIOf/AGENT/NOTARY Notary Expiration Date DLAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) Northeast quarter of the Northeast quarter of Section 12 , Township 29 North, Range 1 West , W. M. ; EXCEPT that portion lying Southeasterly of Old Ness' Corner Road; ALSO EXCEPT that portion known as Flagler Road as described in Volume 1 of Road Waivers, page 571 , records of Jefferson County, Washington. Situate in the County of Jefferson, State of Washington. DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT.THE VEHICLE IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALERS AUTHORIZED SIGNATURE ❑USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). al COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICENFS OPERATOR NUMBER SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX IMPORTANT: Once the application has been approved by the County Auditor/Vehicle Licensing Office, take your application form to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form, obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must return to a Vehicle Licensing office to file the Manufactured Home Application, paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this form for Title Elimination, Removal from Real Property or Transfer in Location, see form TD-420-730, Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation,please cal(360)902-3600 or TTY(360)664-8885. TD-420-729 (R/6/06)W Page 2 of 2 • • . RETURN ADDRESS OLYMPIC NORIIWEST ESCROW, TNC_ 1480 NW SID UHINCK RD. #100 SILVERDALE, WA 98383 ATTN: PATRICIA L. DUNT,AP 360-337-0118 Manufactured Home �TITLE ELIMINATION 1: 1 W41•L'IxdVW TIa1 WASHINGTON STATE DEPARTMENT OF L1p �• LICENSING Application ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ❑REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine, imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 SILVR 44 X 27 11830546AB © LAND LEGAL DESCRIPTION ON PAGE 2 REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE gAFFIXED 0 REMOVED 901 121 008 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION S 12,T29N,R 1 W NE NE © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS JEFFERSON 1 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER KRIS L.KAMPF KA11 1 Pi-i:' L-.`i w' j t j' `; NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 110 CEDAR LANE PORT HADLOCK WA 98339 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER WEBSTER BANK,N.A. NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE P. O.BOX 30 WATERBURY CT 06720-0030 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE M RE T RE 1ST ED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE Signature of Additional Registered Owner and Title,IF APPLICABLE NOT 9£AtlYo MP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNERS NATURE o,L. DU/V"2ttt I OWNER(S) G\P'.••••••'•• .A it I State of Washington Signed or attested ,r7r c�\ON Eko,... it, I County of �, j T_..A t before me Ng' )/ 'Jri'4.. ( A �� z by }:_� .l`-> L k.x)111�'( Signatbre,)� A4-zc;-. =/t 1,t. :z 0 :O No G ,O PRINT NAME OF REGISTERED OWNER NOTARY OR AGE Nf 1 i 'v PTV by {A-I Kit: i A L. .G c;1.t�.A F 4,eit %��•,••.• �1:•_ I PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR 1111-1 OFwPc�`' Title NCI/2\f. ( i>II?L.i (-- AND: .. Dealer No.OR/:c.i1I - .. /'1 At ,,o+:'- 1 DEALERSHIP POSITION/AGENT/NOTARY :`Not2 !Ezpira_tion Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. 0 BUILDING PERMIT OFFICE CERTIFICATION I certify that: iylrthe manufactured home has been affixed to the real property as described. ID a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT N KA'Of\\Q �� .kLt,r��/J- 0 LA))51,61- 445\ bwb4-oo'itA- SIG R Sn etinw) 11 , \O(/Yi'�w� tal12A PC0 TD-420-7 (R/6/06) age 1of2 V . OWNER BUILDER STATEMENT ii 1 3yVd013r13 J i.l�?.ilV '`03 i0 '-. ''� 1 nog��s�?i,'r of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they :re not'--!,':. "aria matt be assuming the responsibility of the General Contractor for the proposed project. j ,ature: Date: 8 " AON `?`; i ii 9i 11 GENERAL CONTRACTOR OR MANUFACTURED ' E INSTALLER: PHONE: Ax '+� jf ° i`� .y' �` _� fkvts�iE /11044.E- C ,SEIty'',cC ( ) •: :.. li _ •�_ MAILING ADDRESS: j ( .74 y P&y i L� L 4 p ,4, 7,9371 EMAIL: CONTRACTOR'S LICENSE { WAINS NUMBER: NUMBER 93 17 ARCHITECT/ENGINEER: PHONE (as-3) 3//.'�G`1b FAX:( ) MAILING ADDRESS: - . EMAIL ' Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ®- New 6 Wood Existing: L ❑ Sewer ❑ Addition 0 Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Z. Height: 111. Individual System ❑ Repair ❑ Masonry SEP Permit#-SCl'v f •c t-£i2..,; ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Z Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: 'jp Public Total: EI.Tr:T�.i(. 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 0 Woodstove ❑ Fireplace Insert ❑ Hot Water Tank 0 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 o,,e c:oll, ly s 45} + . 7 i 1,. Curren Proposed `. »L 7' •-1/E d`y �s t",+�',a l..rs kR4. z,. s ��' :. Main Floor 'Consistency Revile; 4 $?,, c , �,4fi T' , `k':s 2""Floor Base fee: 3°Floor 44dditional Section: :,: ▪i � n, f -•. r a 04 Mezzanine: 'ban'<Checkfee: �F - k' f _ " . Heated Basement State Surcharge fee: •} u s �^ ' � i r.. , Unheated Basement WaterRe - f 21f.*rx; i s �:p.* h r: xe 4 ssk j., Other Unheated 91liRd Approach' fu„ ' "t:�-,�1"C' .t 4"iv"'' ;` >'A' Garage/Carport \ Tt .f Y v �fA r aL j`l; t �a i '��.y ^T�`� tit' 3� Decks s tr ,. s M r i wr` 3a }a. 5�'xy'c '�. Receipt Number: x , '^i' = ie,, p ▪ �,s t1 A ram., Other Cash/Check Number 1 ,, -4 3 ESTIMATED COST(REQUIRED) Date: - -.---..A,, ;� " s s .Fair market value of all labor arid materials foundation to finish O(04 • i�+ - •i} ar, 1 initials: . Ii.„,„6,), . + 4s. 3 •h G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc o� JEFFERSON _ NTY " ,r f f ,; ,rI , : i :h i DEPARTMENT OF COMMUNITY C�EVEL�PM'ENT--------------���t !�� 621 Sheridan Street • Port Townsend •Washington 98368 .`' r I ,, 360/379-4450 • 360/379-4451 Fax NOV - 8 2004 '`` I ,/,, N 0�O www.co.jefferson.wa.us/commdevelopment j Master Permit Application MLAt'T j 0 4 —cc.' E-. Project Description(include separate sheets as necessary): Tax Parcel rY Pro Number: !i'/ �I / `1£ 3 Size: . :6 f' hoz e:S (acres/square feet) Site Address and/or Directions to Property: ?CO I.Ja fjiz 61161. 6.4,4 '%E C' /4. .5 i 7.r t-7d, Property Owner(s)of Record: %i b© glei2At,Jr;:,1 ���1 Telephone: LEI-- 7 :5 t' 7 Fax: 't r�i �V� 1‘�, . email: Mailing Address: il_i l s c,1/ -,r,i1`I- f. < ieb ' r ,rt.0 c.L,-I'. .5-r ei Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: . What kind of Permit?(Check each box that applies) ❑ Building ❑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 El Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** -tit Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** '>g Address 'IA Road Approach 0 Planned Rural Residential Development(PRRD)IAmendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** V 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 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 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 access d right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any/etre r i ins.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: G - Date: JO ;) /-e y 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 olate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if y u a e• ' nce with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transf 'li or adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. 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