HomeMy WebLinkAboutBLD2004-00731 b'TJILDING PERMIT APPLICATII� MLA04-00652
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00731 Received Date: 11/18/2004
SITE ADDRESS: 1441 THORNDYKE RD
PORT LUDLOW, 98365
OWNER: MARK JOHNSON PHONE: (360) 437-9668
ANNETTE JOHNSON
11 WARBLER LN
PORT LUDLOW WA 98365
SUBDIVISION: TRAILS END HOMESITES Block: 3 Lot: 25
PARCEL NUMBER: 950100324 Section: 16 Township: 27 N Range: 01 E
CONTRACTOR: WHITEY JOHNSON PHONE: 779-9884
PO BOX 1110
SUQUAMISH WA 98392
Contractor's License WHITEVG159DN Expires 03/15/2005
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE & DECK
ALSO A/G 120 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 241,145.00 MAIN: 1,312
CODE EDITION: 2003 ADD'L: 1,353 HEAT TYPE: PRO
OCCUPANCY: R_3 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: 5N OTHER:
GARAGE: 484 SHORELINE:
CONST TYPE: SETBACK:
DECK: 81
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: BRIDGEHVN
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: // /`q /0+� F&W _ Landslide
!l Shoreline _Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: �i ✓p2t ?
Permit $1,788.95 KAS 11/18/04 68722 1"Z PPved t n
Plan Check $1,162.82 KAS 11/18/04 68722 2004
State Building Code $4.50 KAS 11/18/04 68722 DEC 2
Potable Water Application $52.00 KAS 11/18/04 68722 Jefferson County Planning
Total: $3,008.27 & Building Department
-0,0 _
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BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD04-00731 Received Date 11/18/2004
SITE ADDRESS: 1441 THORNDYKE RD Issue Date 12/21/2004
PORT LUDLOW, 98365
APPLICANT: MARK JOHNSON PHONE: (360)437-9668
ANNETTE JOHNSON
11 WARBLER LN
PORT LUDLOW WA 98365
SUBDIVISION: TRAILS END HOMESITES Block: 3 Lot: 25
PARCEL NUMBER: 950100324 Section: 16 Township: 27 N Range: 01 E
CONTRACTOR: WHITEY JOHNSON PHONE: 779-9884
PO BOX 1110
SUQUAMISH WA 98392
Contractor's License: WHITEVG159DN Expires: 3/15/2005
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE & DECK
ALSO A/G 120 GAL PROPANE TANK
CALL IN FOR THE REQUIRED INSPECT! S THAT APPLY TO YOUR PROJECT.
SETBACKS: Ok izA.#1�G
UFFER: /Ja
Footing: OK 10_7/oL fr
Foundation: Ok p/cc 460S S/z6
Stormwater FINAL!(Approval: QK 3//
Underground Plumbing:
Underground Insulation:
Shear Wall : QX fee/l�14;54s 01/OS L
Framing: Doi( q/, /os
Plumbing: QK/4/14-(615 i As �l
J Propane Tank/ Lines: l /Up (�145 2lN� a �4(d r
Insulation: QxW t�n /nMMS 4//%c6
Sheetrock: OP 5---i6 •b\
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: 2) _'t,r ..4?,14v..1 0 /'zWe;3
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 # BLD04-00731
1.) A vegetative buffer of 35-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.
2.) A Geotechnical Report was submitted in conjunction with this application. The report
addressed the stability of the geologic hazard area. A setback of 35-feet shall be
measured perpendicularly from the top or toe of the geologic hazard to the proposed
single-family residence.
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 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.) 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.
9.) MANDATORY MEASURES OF HIGH 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.
• •
10.) MANDATORY MEASURES FOR HIGH RISK 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 requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106
for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e)of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
11.) 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.
12.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
13.) 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).
14.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
15.) The building height is not to exceed 35 feet.
16.) Minimum setback from Thorndyke Rd right-of way is 20 ft. Minimum setback from
Peabody Way right-of-way is 20 ft. Minimum side yard setbacks are 5 ft. Environmentally
sensitive areas further impact setbacks.
17.) A minimum of two (2)on-site parking spaces are required for the single family residence.
18.) A stormwater plan for a medium project has been submitted and approved by the
Department of Community Development. Once the subject permit has been issued the
applicant shall fully implement the provisions of the submitted plan and contact the
Jefferson County Department of Community Development to arrange a schedule to
inspect the property for plan compliance. A Certificate of Occupancy will not be issued
until the Department verifies plan compliance. No clearing for roadways or utilities shall
occur on the project site until clearing necessary for the installation of temporary
sedimentation and erosion control measures have been completed.
19.) A minimum setback distance of 35 ft from the top of the bluff shall be established for all
structures. Additionally, a vegetative buffer of 30-ft shall be permanently maintained along
the upper bluff edge within which the regrowth of native (lower-growth) plants shall be
encouraged.
20.) Septic tanks shall be placed as far back from the top of the bluff as possible and
drainfields that may be constructed on the property shall be at least 50 ft from the top of
the bluff to prevent daylighting of effluent along the bluff face and saturation of the soils.
21.) Grading and prepartaion of a proposed homesite shall be conducted in a manner that will
allow runoff water from the site to drain to the west, toward natural drainage depressions
along the shoulder of Thorndyke Rd, rather than east, toward the bluff face.
I
22.) An effective water collection system (gutters and downsprouts) shall be installed on any
new structures. Collected water shall be directed away from the bluff face.
23.) In no case shall water from any source be allowed to discharge onto the bluff face, and
areas where excessive water flow occurs shall be protected by catchment boxes or
curtain drains that collect and shunt the water away from these areas.
24.) Efforts shall be made to promote and maintain a healthy growth of deep rooting vegetation
on all slopes, whenever possible, to aid in retaining surface soils and to reduce the effects
of erosion. Shrubs and plants used on slopes shall be deep-rooting varieties and shall be
selected to minimize the need for heavy watering. The planting of lawn grasses shall be
limited to relatively level ground.
25.) The accumlation of construction materials, stumps, felled trees, branches, cuttings or
other yard debris on the bluff shall also be discouraged as these materials may inhibit the
growth of healthy vegetation. Walking or climbing on any portions of the bluff, which may
loosen or disturb ground materails, shall also be avoided in favor of established
pathways.
26.) Periodic inspections of the bluff face shall be conducted, especially following periods of
heavy rainfall, to determine the location of any new springs, seeps or areas of excessive
erosion, anjd to identify any unstable conditions.
27.) Health Department must be notified for footing and foundation inspection prior to the
pouring of any concrete to verify setbacks from drainfield and roadside ditch. 48 hr notice
to be provided by owner/contractor.
I:\F_BLD_Permit_Buildng.rpt 10/29/1999
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,:_ ` DEPARTMENT OF COMMUNITY DEVELOPMENT NWT
, „ 621 Sheridan Street• Port Townsend •Washington 98368 . ,gill
360/379-4450 • 360/379-4451 Fax
O http://www.co.jefferson.wa.us/commdevelopment/ ` A _ Q / '"
STORMWATER SITE PLAN SUBMITTAL
BCD
MLA# oq/ ����/ PROJECT/APPUCANT NAME: ZIA(77'7 r ""CTeY o
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.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
3. Describe the existing vegetation. Indicate nativeAvegetation areas on the site map. �;t`
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4. Describe the existing soils. Indicate soil type on the site map.
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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.
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6. Describe any excess levels of noise generated by the proposed use or activty: APPROVED
,voti, STORMWATER PLAN
DEC 17 2004
,
JEFFERSON COUNTY
storrnwater site plan template—rev.10/12003 DEPT.OF C �1 NR LOPh�T 5
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7. Descnbe-signint geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,.etc.),op the site. Indicate location on the site map.
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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.
9. 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.
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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 pert rma e g ss and standards liicable to the prof
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stomrwater site pran template—rev.1IY12003 6
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13. Describe the water quality system.
NOV 1 8 2004
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.
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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.4-1( rDF' Col t✓ i"1Po ut. i -'A ' iS F'L '"t �
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 SWPPPaddresses 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.
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2. Establish Construction Access.
3. Control Flow Rates.
4. Install Sediment Controls.
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5. Stabilize Soils.
6. Protect Slopes.
7. Protect Drain Inlets.
8
storwater site plan template—rev.10/1/2003
m
•
12 Required Elements—Construction SWPPP(continued) t '
8. Stabilize Channels and Outlets. ' NOV 1 8 2004
9. Control Pollutants.
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.
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.
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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).
Or>I '.
5. Construction Phasing.
a. Construction sequence
Sint
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. FinancialOwnership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Descnbe 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
storrnwater 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. �}y
(LANDOWf I OR ED RESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
1�Oy 8 2004
A ,t
•
12
stounwater site plan template—rev.10/12003
I . OWNER BUILDER STATEMENT 1,
..,e 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:
VOR
GENERAL CONTRACTOR ORMANUFACTUR€-D-OME INSTALLER: PHONE: "' `" y FAX:
iR.I F-r c f e7,14..)a-0 e..� U`."'"�-t,, (_3.,. 1.)1 Y- 4 t.7ti:i (--ir_"CO)7 i / Ll t1 d 1- (-:%(-,,z))'i'or - L...:
MAILING ADDRESS:
CONTRACTOR'S LICENSE WAINS -11")r
NUMBER: 1 ` NUMBER La? 4? 2
ARCHITECT/ENGINEER: PHONE ( ) VAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: T
❑' New 0' yyng: -, i;�; ype of Sewage Disposal:
,_. ❑ Sewer
0 Addition 0 Steel Proposed:- Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: _77.,, Height: ,C'Individual System
0 Repair ❑ Masonry SEP Permit# O4-•L
0 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:
0 Underground Tank Above ground Tank Size of Propane Tank: )
0' Heat Stove ❑ Cook Stove '❑ Woodstove 0 Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove 0 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 Officii'Uso Only
Current Proposed Amount
Main Floor r 1 Consistency Review:
ri '` cJ(P � O
2r"'Fkor
{ .` . tat ) } 0°1 Base flee: I t T g 'Is
3 Floor ,AilditieaaLSedion,
f , i (OP ga
Mezzanine: Plan Check fee:
Heated Basement
T Stati.;Surcharge fee: 1, J6
Unheated Basement Pot Water Review fee: ,.
5.
Other Unheated 911/Rd
API h fee; --+-r--,
Garage/Carport Q
4131" 501 r 5 I TOTAL: $ �_J� _
Decks e t 1 q031 _RecelPtNuMbOr;. _ (gY 7OD
Other OANumber
ESTIMATED COST(REQUIRED) Date:
it/47O it
•Fair market value of all labor and materials foundation to finish M ,yy�4 a
,:,9 Initials.
INN 1 CV0
G:\PennitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
4rrili----s°Nco JEFFERSCOUNTYa,
, DEPARTMENT OF COMMUNITY DEVELOPMENTS` `� 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�qS,ZtING'/- www.co.jefferson.wa.us/commdevelopment ) 8 2004
Master Permit Application MLA: QAa
Project Description(include separate sheets as necessary): " -
Tax Parcel } "_� 3 3 "` "
Number: 4 - � - -��- Property �� �: �y�'>:a ;-` ,
'> ,_>;.) Size: 1'11 (acres/square feet)
Site Address and/or Directions to Property: '', -
Property Owner(s)of Record: t,r,,.,c"-:f,r
Telephone: .='l_ 15 -%i 71. / (G G r� Fax: email:
Mailing Address , f .l Jfyr C: , - - .�'.-, 1 J�'..T l.-il,I-`i. ')t p-i v/Jf: (5(`;i :,>-�
Applicant/Agent(if different from owner): :/7 ,IA-.)). , ,. 1
Telephone: 1-'--(7 -2 ,,` 01:7 41 Fax: ', ,5 ,. ,;3?;_:.-7 email:
MailingAddress: ', N:.,�),' ' f - ;i .,/.,/ = /)(E- j.? ;a
What kind of Permit?(Check each box that applies)
0 Building ❑Variance(Minor,Major or Reasonable Economic Use)
0 Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
) Single Family_ ❑ Discretionary"D"or Unnamed Use Classification
,Er Garage :Attached)Detached ❑ Special Use(Essential Public Facilities)**
❑Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* 0 Binding Site Plan**
❑Change of Use ❑ Long Plat**
0 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 ❑ Shoreline Management Substantial Development**
0 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:
F D)ESIGNATION OF AGENT
I hereby designate 0'- ,_ , to act as my agent in matters relating to this application for permit(s).
'
r
OWNER SIGNATURE r - `: �/
• � ----.—_ Date: /�"�,���- c
By signing this application form,the owne/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or ifs 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 and right entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any requif e¢latgar inspecti ss and right of entry to this property shall be requested and shall occur only during regular business
hours. / i ^
Signature: L d. l —��__ Date: { i
/
The action or actions Applicant will dertake 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 e q ~t ..ment code.The Applicant acknowledges that he,she or it holds individual
and n
res Ens bi for adhering to andcbmplyingdisclaimer and
, e ESA. The Applicant has read this signs and dates it below.
Signature:non-transfer
,¢. "-. �,.--- Date: /& . - J} — 0 ,ai
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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