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HomeMy WebLinkAboutBLD2004-00723 • 9 M LA04-00642 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00723 Recei d Date: 11/12/200 SITE ADDRESS: 3663 WEST VALLEY RD CHIMACUM, 98325 APPLICANT: STEPHEN GRIMES PHONE: 360-732-7777 DIANA GRIMES 14113 MADRONA RD SW PORT ORCHARD WA 98367 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 901342003 Section: 34 Township: 29 N Range: 01 W CONTRACTOR/ DEMOPRO PHONE: (206)255-3711 DEALER: 20026 BALLINGER WAY NE#203 SHORLINE WA 98155 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MANUFACTURED HM & ADD'L SECTION MODEL MEADOWBROOK SERIAL#09135024XTLL TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: LIBERTY SETBACK: VALUATION 109,900.00 YEAR: 2003 LABOR & INDUSTRIES APPROVAL? SIZE: 66 X 39.9 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO Exist: Exist: STORMWATER: YES NO Prop: 3 Prop: 2 AREA Plat Conditions Total: 3 Total: 2 Wetland Erosion Seismic Streams Flood Way Floodplain Routing Date: i' /(C/ F&W Landslide C Cre? Shoreline Aquifer Type Amount Paid By: Date: Receipt: (� V T e APPROVED Manufactured Homes $154.00 BAC 11/12/04 68584 Add. Manufactured Home $32.00 BAC 11/12/04 68584 DEC 2 2 2004 Potable Water Application $52.00 BAC 11/12/04 68584 Jefferson County Planning Total: $238.00 /L Buildin Debartme Cl r r III • • . ,¢So1v 0 06. JEFFERSON COUNTY 4 y DEPARTMENT OF COMMUNITY DEVELOPMENT • 621 Sheridan Street • Port Townsend • Washington 98368 NOV 2 2004 4.101,, 360/379-4450 • 360/379-4451 Fax q`S`$IN��S p� www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: D 6 l Z Project Description(include separate sheets as necessary): Tax Parcel j�( /� Property Number: DI 3 T Z�/0 Size: (acres/square feet) Site Address and/or Directions to Property: 3W(03 W, Vcdky (201 l 'w iCU1 iV4 Property Owner(s)of Record: .ep�pri .4.Dona__ C-rirnes / a$32S Telephone: ( j, 85'7 4147 r Fax: kOrn t°f✓._ 15 j. -10p, email: 5j�Pbe0.Yld 10.vuh G�ltti nej Mailing Address: NH 5 Madam& gel. s.w. TOr Orchard ,W�- q'd3b`j @E'ar littk.,net Applicant/Agent(if different from owner): `iQ r+ne. Telephone:Celt 2s3) 4.7.5 -.low eel! jr. b )S7/-gpgz. email: Mailing Address: - What kind of Permit?(Check each box that applies) Building U Variance(Minor,Major or Reasonable Economic Use) Demolition Permit u Conditional Use[C(a),C(d),or C]** Single Family U Discretionary"D"or Unnamed Use Classification Garage Attached/Detached U Special Use(Essential Public Facilities)** )(Manufactured Home U Boundary Line Adjustment Modular U Short Plat** Commercial* u Binding Site Plan** Change of Use u Long Plat** Address I Road Approach U Planned Rural Residential Development(PRRD)/Amendments'"` Propane u Plat Vacation/Alteration** Allowed"Yes"Use Consistency Analysis U Shoreline Master Program Exemption/Permit Revisions** Stormwater Management I I Shoreline Management Substantial Development** Site Plan Approval Advance Determination(SPAAD)* u Shoreline Management Variance Temporary Use I Comprehensive Plan/UDC/Land Use District Map Amendment Wireless Telecommunication* J 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 y?° ' prp to act as my agent in matters relating to this application for permit(s). V • OWNER SIGNATUR LQ� 1 Date: f,/ii jtp/ 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 required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. i Signature: a},i s,� 1.[_ �n�,Vr yi.1O Date: 1 i/i f/e4 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-trap erabl re p nsibility for(a h ring to and complying with the ESA. The Applicant has read this disclai era d signs and dates it below. Signature: �f "`"` . 4irni4 Date: ,/ - 1, ,fin C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc • • 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 #: BLD04-00723 Received Date: 11/12/2004 SITE ADDRESS: 3663 WEST VALLEY RD Issue Date: 12/22/2004 CHIMACUM, 98325 APPLICANT: STEPHEN GRIMES DIANA GRIMES 14113 MADRONA RD SW PORT ORCHARD WA 98367 SUBDIVISION: Block: Lot: + PARCEL#: 901342003 Section: 34 Township: 29 N Range: 01 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: NEW MANUFACTURED HM &ADD'L SECTION MODEL MEADOWBROOK SERIAL#09135024XTLL MAKE: LIBERTY YEAR: 2003 SIZE: 66 X 39.9 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 12/22/2005. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. y Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): I�,-a,s.-b/ Stormwater FINAL Approval: Blocking/Plurnbin . ---- 05_ Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 41 W7% OK -car .P,Na--/ 4/1/ HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSP CTION 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 November 29, 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, the following ESAs were confirmed to be present on the subject property: Susceptable Aquifer Recharge Area (SUSC). 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.) The applicant is proposing to create or add 3,436 square feet of impervious surface and 6,960 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 5.) 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. 6.) A Medium Stormwater 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. 7.) 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). 8.) The revised site plan as submitted on December 9, 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 20, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 9.) 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. 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.) Setback from West Valley Rid (C514109) right-of-way is no less than 210, the setback from the edge of the private easement right-of-way is no less than 20 ft., right side and rear setbacks are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more restrictive setback shall apply. 15.) 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. 16.) 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. 17.) A minimum of two (2)on-site parking spaces is required for the single-family residence. 18.) This parcel is being accessed from a private easement which is off of West Valley Road (C514109). An address of 3663 West Valley Road has been assigned to this parcel. 19.) A septic permit (SEP04-00197)was approved September 3, 2004 for a capacity of 360 gallons per day. 20.) This parcel is served by a individual well. 21.) This is a legal nonconforming parcel designated as Rural Residential 1:10 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. •• • Z 194,1 C� 3 ILL! • sJ iIJ z ‘1,1.: tftio _ j-' ri) ?lb-Niel ..''.1, :..,..g.i, f •/ I ./� jr; BOO? z t AON ; �! �'`� ... +St i �C `/ . - --. • '....-:."" '44:; g 1 • t t iii // / a \ �� y�0 \�1. Fcn rClN1Vp 01 se eL � ci �� — 1 . L OV021 A371VA 1S3M • w4") °°e, JEFFERSON COUNTY w ,-, y.„, ' DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 qS, NO.Q 360/379-4450 • 360/379-4451 Fax http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# ol-t-' CG1"(v PROJECT/APPLICANT NAME: hen"t-bfant L. Emotes 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. ...�u.i,,i i ._ �[ i 11. •.r t AA: i tC .'(..t b`�( t t..;.tr_ tµ�, L s y� ,, Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. C?&ttSE: cT t .4c, f,71i7 (to.5,i(41.,. C Ltt.' ti, `41,i . i S AJ •-1'C' ' C J { �i'; t ,l t r i 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. t•ti.i4' 1:L 6, C iwi s -.CI c t t'116�A ! att:ii`i . Z ik 'L a ,o it-+it,a,3 ct,i itai_k itsk, 1'1( i (,i :5 t .f.t 4'11- bi t 16`•L;;,; I V< chi+w'4t.flv'. 4. Describe the existing[ soils. Indicate soil type on the site map. ` / t� � .lf�'t`(11 i��..-av- (i�+7j?v2 t. x4t t iC, �(,j ✓4t-t.t..� 01 '`31 tt , 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. L$)et €t tUltins .stiL' -c. :."),tit! . '¢' 5c / avr }�P ET Ct .A . 6. Describe any excess levels of noise generated by the proposed use or activity: stormwater site plan template.doc-rev.10/12/2003 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.). • �' �`�' 11_'tth u `i 1,.i 1iC`sZ14 3 en. `11:L.L 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. 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.] KVA- 11. Describe the performance goals and standards applicable to the project. L�t/ lt;C,�, 1:l.1 ►`t.i.It-I -(Lc it ( 12. Describe the flow control system. 1'; /'f stormwater site plan template.doc-rev.10/12/2003 6 • • 13. Describe the water quality system. I /17 j'a _ �ij1` 14. Describe the conveyance system analysis and design. • i 1/i 15. Describe the source of fill material, physical characteristics of fill material,and deposition of excess material. f (i /1,�1 i 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. f f/u1 . 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. iJ 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. AVA-- 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. /.4 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.doc—rev.10/12/2003 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. f n (( 1. r , > it( It/%4 c , > t Ns 3. Control Flow Rates. /1. 4. Install Sediment Controls.fir 5. Stabilize Soils. (' ( �s i. / c.�.1'-! �JJ i' t iL- 7' ! i1S 7..7;41 A • II / • 6. Protect Slopes. f 7. Protect Drain Inlets. r / ,t stormwaler site plan template.doc—rev.10/12/2003 8 • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 1 �`"rP.- 9. Control Pollutants. n i / l' . V tr 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). t l` ��.)I.4 i 12. Manage the Project. e 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). fond 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. N/A stormwater site plan templale.doc—rev.10/12/2003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. ft* 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. Construct n sequence t raid,'t nt fte41461 11.e%te agralPe b. Constructiop phasing(if proposed) N//�F/f�� 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). Provide a construction schedul�^ eet, II. Wet Season Construction Activities. a. Proposed wet season construction activities. n SZalt , i nS�a,�.C. r�IFt`t, ins +.GQ c 361013-e • 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. NiA- 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. a. Sediment Ponds/Traps. b. Waterways. Diversions. /1V/k c. d. Runoff/Stormwater Detention Calculations stormwaler site plan lemplate.doc-rev.10/12/2003 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. (IANDO ER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: • slormwaler site plan templale.doc-rev.10/12/2003 12 • OWNER BUILDER STATEMENT NOV 1 2 i�'j�- 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 assumi t e responsibili of the" General Contractor for the proposed project. Signature: � C.C./)W/ Date: It///rl611 . GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: •1 Lw ds{, j.; 4.FA ,tiop� (ZD&�) '1Z3--43 (2ob) 36S=-3i71/ MAILING ADDRESS: 1 LZ r 6/ifiler Wtw N1•7 Share li ne 1 d ill/SC CONTRACTOR'S LICENSE WAINS NUMBER: DEMDPRaZMW NUMBER I ?j?V'7 ARCHITECT/ENGINEER: MAN Lr .,t.u�r ' NO___e PHONE ( ) ✓ FAx: ( ) MAILING ADDRESS: '^LJ((1711( 1 /� jit7T►1 EMAIL den-)ern) Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: )(NewWood Existing: 2 * ❑ Sewer Addition Steel Proposed: Ban ❑ Community System Alteration/Remodel Concrete Total: 2 Height: Individual System Repair Masonry SEP Permit#� i —oo 0197 Demolition `PC Bedrooms: Water Supply: pp y. ohruckike404d Existing: 3 Setback: X" Private well ❑ Two Party Type of Heat: No rr•� Proposed: 1 Public Total: 3 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: i Underground Tank i Above ground Tank Size of Propane Tank: i Heat Stove i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i 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. ISquare Footage For Office Use Only Current Proposed Amount Main Floor T Consistency Review: 2-Floor F Base fee: Nip 1 S f 00 - 3`d Floor Additional Section: IV/tv .00 Mezzanine: Plan Check fee: Heated Basement N/4 State Surcharge fee: .6mm..n... Unheated Basement i Pot Water Review fee: 05•co Other Unheated N/A 911/Rd Approach fee: Garage/Carport Wilk TOTAL: $ 7 l -i -W Decks / W/A Receipt Number: S/ - Other Cash/Check Number: cv V t�[T ESTIMATED COST(REQUIRED) Date: ''f+�� .Fair market value of all labor and materials foundation to finish It(r2-(C4—Initials: 1 C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc r . RETURN ADDRESS WASHINGTON FEDERAL SAVINGS PO BOX 2848 SEQUIM, WA 98382 L1STATD rtmrn EOF tWASHINGTON MANUFACTURED HOME • AS CH CK ONE LLI/ll aof ®TITLE ELIMINATION APPLICATION IICEflSIflG OTRANSFER 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) 2004 70 X 42 09L35024XTU ® LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE EaAFFIXED 0 REMOVED 901342003 LOT BLOCK PLAT NAME SECTION/TOWNSHIP/RANGE © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS TWO ONE NAME OF REGISTERED OWNER STEPHEN M GRIMES NAME OF ADDITIONAL REGISTERED OWNER DIANA LAVONNE GRIMES ADDRESS CITY STATE ZIP CODE PO BOX 454 CHIMACUM WA 98325 NAME OF LEGAL OWNER WASHINGTON FEDERAL SAVINGS NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE PO BOX 2848 SEQUIM WA 98382 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: 1 4 Signature of Registered Owner and Title,IF APPLICABLE . .e.\,%;3)1'\C.'r \ s -) 4 pL 1,i k.1 ::.? Signature of Additional Registered Owner and Title,IF APPLICABLE '+>�J �(�' i G�j�,3Ylfti(- �- ' ,C f rt,f,:'I NOTA KctA. /lb_ I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE `�� er>•<•'''a�,j'''•.S',,r,State ofWashington Signed or attested 0, vivf.F• !. County of CLALLAM before me on .12/30/04 Q ••V A• JUNE a• 1 ( * 15 ">• ( STEPEEN M GRTMF.S Signature /' -/// `, X. i N� 2006 6 PRINT NAME OF REGISTERED OWNER NOTARYNOR(AG�tVT • o•• I , f� 7.10: OF �N°,•0 Y DIANA LAVONNF GRTMF.S LIZ XT.TPPERT' O • WASH. \ PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY •//.A i v°�\`,`I Title NOTARY AND: County/Dealeer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 6/15/06 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAMFF.(TYPED OR PRINTED) , _ i TITLE COMPANY/PHONE NUMBER V'4 i "=' -is.-+,. FIRST AMERICAN TITLE CO (360)385-1322 SIGN TU E/POSIT " -� DATE :I E- / .-^"r_� (. /p'r / �� ,� l r ' /�j.1.-( I1 1 L. �'L VC l J/SA/t Frriaiize this imp cati n w th a Licensing Agent within 10 calendar days of the date Title Company Representative signs. ® BUILDINCiP RMI-OFFICECERTIFICATION I certify that: til,the manufactured home has been affixed to the real property as described. kka 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# l IW� Utz., l-{6)2 ,:xA gf't JEF ERSON CO NT' DCD (360)379-4450 BLD04-00723 SIGNAT RE/P SItyION ":., /q J) icj-fd.)-71,l DAT ( l/TD-d20-79 MANU HOME APPL(�19 9B)OR Pageof 2 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELI ATION OF TITLE/REMOVAL FR M REAL PROPERTY. ��� �// Signature of Legal Owner and Title,IF APPLICABLE' ,6-0 % Signature of Additional Legal Owner and Title,IF APPLICABLE NOTA�'I� d!UFAWily I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE .a\\\l�,v(Li ppr. / s .\•..41�?I`,ry., 9 . I State of Washington Signed or attested 12 -- •.• •�,�.. r4A�• County of CLALLAM before me on /30/04 JUNE 9N� CINDY MCCLAIN FOR a'y'.-' 15 •* by WASHINGTON FEDERAL SAVINGS Signature j -r` /., .1 f.. ' PRINT NAME OF LEGAL OWNER NOTARY OA'A M 9�F ')'I�•, Z LIZ KLI PERT /�//"O.'.V.111..C'>v��� by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY C /Office No.OR bi //��gRYIPv�� I TitleDEALERSHIP O POSITION/AGENT/NOTARY Y AND: Notary DelerNDate Expiration6/t5/06 DLAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office THE SOUTHERLY 330 FEET OF THE NORTHEAST 1/4 OF THE NORTHWEST 1/4 OF SECTION 34, TOWNSHIP 29 NORTH, RANGE 1 WEST, W.M. , LYING EAST OF THE RIGHT OF WAY OF THE COUNTY ROAD, AS CONVEYED BY DEED RECORDED APRIL 27, 1981 UNDER AUDITOR'S FILE NO. 271989, RECORDS OF JEFFERSON COUNTY, WASHINGTON. SITUATE TN THE COUNTY OF JEFFERSON, STATE OF WASHINGTON. CI 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 NUMBV.1 DATE OF SALE .ldt�.+;, ems,,.,. (.: . ,..- ,/!`.,.r ) 1, PURCHASE�P RICE^') TAX JURISDICTION/TA RATE DEALER'S.UTHORIZED SIGNATURE 1 "� 1 r`+ 0 USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). 9 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 TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/8/98)OR Page 2 of 2