HomeMy WebLinkAboutBLD2004-00807 •
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#: BLD04-00807 Received Date: 12/20/2004
SITE ADDRESS: 53 COMMERCIAL AVE Issue Date: 1/20/2005
PORT TOWNSEND, 98368
APPLICANT: CYNTHIA EDWARDS
CHARLES EDWARDS
PO BOX 2101
SEQUIM WA 98382
SUBDIVISION: JUNCTION CITY Block: 14 Lot: 1-3
PARCEL#: 964501403 Section: 13 Township: 29 N Range: 02 W
CONTRACTOR/ COACH CORRAL INC PHONE: ($11017083
DEALER 377 S BURLINGTON BLVD ace),/ (d- l51 BURLINGTON WA 98233
Contractor's License COACHC*254MJ Expires 6/28/2005
PROJECT DESCRIPTION: NEW MANUFACTURED HOME-SERIAL -#9U910380P &
NG 600 GALLON PROPANE TANK
MAKE: SKYLINE
YEAR: 2002
SIZE: 68x27
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 1/20/2006.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED):
Stormwater FINAL Approval: '-4e)-1 JGc
Blocking/Plumbing:G -- ��1 �--
Propane Tank/Lines 7t+A-P► .-„Z-L. . ��A ,, WC'S
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps:(1/./(,, 6-5/
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
IPUILDING PERMIT APPLICA L MRL Review
705
e iew iew T Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00807 ec 'ved Date: 12/20/2004
SITE ADDRESS: COMMERCIAL AVE
PORT TOWNSEND, 98368 aar'
OWNER: RAM RODERS '..0 jd) 9, 10( PHONE:
4503 OLD ARDINER RD
PORT TOWNSEND WA 98368-9778 3 ecouur 1,\AI Pvit83$0-
SUBDIVISION: JUNCTION CITY Block: 14 Lot: 1-3
PARCEL NUMBER: 964501403 Section: 13 Township: 29 N Range: 02 W
CONTRACTOR: COACH CORRAL INC PHONE: (800)708-4663
377 S BURLINGTON BLVD
BURLINGTON WA 98233 1
Contractor's License COACHC*254MJ Expires 6/28/1999 IN 1 r
REPRESENTATIVE: COACH CORRAL INC PHONE: (360)661-12571
PO BOX 2101
SEQUIM WA 98368
PROJECT DESCRIPTIOr NEW MANUFACTURED HOME-SERIAL -# 9U910380P &
A/G 500 GALLON PROPANE TANK
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 56,000.00 ADD'L: HEAT TYPE: PRO
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUD PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: 3 Exist: 2 Wetland Erosion
Prop: Prop: Seismic Streams
Total: 3 Total: 2 Flood Way Floodplain
Routing Date: oD/0 F&W Landslide
/ ) Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid Bv: Date: Receipt: -. .+ D `/
E1
® ■ NO V
Permit $154.00 BAC 12/20/04 66861 /"'�
Potable Water Application $52.00 BAC 12/20/04 66861 JAN 2 0 2005
Total: $206.00
Jefferson County Planning
& Building Department
b°f Oka K V
JACK WESTERMAN III • Jefferson Counikurtlousc
ASSESSOR Po Box 1220, 1 art Townsend, WA 911368
w (:tc0) :Ills-910:;
91I ()PSI 1 `N)
MOBILE HOME INFORMATION FORM
OWNER'S AME/MAILING ADDRESS: DEC 2 2004
NAME: l► d i e Nit 2
ADDRESS: Po QOX !0 I 15-ep"►)-. , Ix) 1 r'/ a,
PHONE NO. 3(,¢D 13'9 & 0
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1)MOBILE HOME DATA: CO
py
(A) MAKE � ) {�-L 1 ,l rL-L (B)MODEL c,t (C)YEAR c9-66a.-
(D) LENGTH Le 2 (E) WIDTH a 11 (F) SERIAL # CI L( 9 l a 3 SOP
(G)YOUR PURCHASE PRICE (Do not include sales tax)5la 1 O1 j,O )PURCHASE DATE Fe6 000
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF(( NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE CQ ALd (..br �
ADDRESS .0 11.CI L.-w` S‘r1.OY'e ci, ( ..e,l Livu ha rY vs 1,.1) 1v
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAS EAR? Yes No
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year.
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes �o
(B)IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Space#
(C) IF NOT LOCATED IN MOBILEAIOME PARK-
NAME OF LAND OWNER: c x\d I.e (_, �l tx.r 1-e_S
LOCATION AD ESS 1' rn rn fe Q i cj. I9: A 2-Y TbLnfS fl
REAL PROPE #/DESCRIPTION a 614^ 5D/- 4/0_3
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Signature of applicant
THANK YOU FOR YOUR HELP!
6ss-e Q_
JOD►I COSSELL, Property Technician
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SPECIAL CONDITIONS CASE # BLD04-00807
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on January 12, 2005 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:
Landslide hazard area 2; SUSC aquifer recharge area; coastal SIPZ.
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.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
5.) 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.
6.) 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.
7.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
8.) 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.
9.) 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."
10.) All construction activities shall not encroach upon the landslide hazared area buffer. This
includes the storage or preparation of materials.
11.) 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.
•
12.) Critical Aquifer Recharge Areasmay require special protection measures t• 9
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.
13.) 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.
14.) 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.
15.) 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.
16.) MANDATORY MEASURES FOR 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.
17.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
18.) The applicant is proposing to create or add 3484 square feet of impervious surface and
3484 square feet of land disturbing activities.
19.) 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.
20.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
21.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act(SEPA) pursuant to WAC 19'-11-800(1)(b)(i).
•
22.) The site plan as submitted with the manufactured home installation application on
December 20, 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
January 12, 2005 shall be resubmitted for review and approval by Jefferson County
Department of Community Development.
23.) This approval is for a manufactured home installation and 500 gallon above ground
propane tank 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.
24.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
25.) 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).
26.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
27.) The building height is not to exceed 35 feet.
28.) Minimum setback from Commercial Avenue right-of-way shall be 20 feet. Minimum side
and rear yard setbacks shall be 5 feet.
29.) 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.
30.) 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.
31.) A minimum of two (2) on-site parking spaces shall be provided for the manufactured
home.
32.) The lot has been designated as RR 1-20 under the Jefferson County Comprhensive Land
Use Map effective August 28, 1998.
33.) An address of 53 Commercial Avenue, Port Townsend has been assigned to the lot.
Commercial Avenue is a county local access road (C501009).
34.) A septic permit(SEP04-00304 has been issued on January 10, 2005. A road approach
permit (RAP04-0330) will be issued with the building permit. A building permit
(BLD04-0808) for a garage will be issued with the manufactured home permit.
35.) Potable water is provided through an approved DOE water system managed by PUD.
36.) A Declaration of Easement for septic purposes was recorded on September 12, 1997
under AFN 403706.
37.) A Declaration of Restrictive Covenant has been recorded on January 18, 2005 under AFN
493914 for the purpose of maintaining a zero lot line setback for building and septic
purposes ONLY.
r ffc JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT p
621 Sheridan Street • Port Townsend •Washington 98368
IO 360/379-4450 • 360/379-4451 Fax t
y
' NO http://www.co.jefferson.wa.us/commdevelopment/
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STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# PROJECT/APPLICANT NAME: Ra(Y,Ofl B Radi 1zcs C!Q 6Areit 4(N(Ct.-d
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. tt /�
tx 1 C�Lr ttin.,i. CLvti«< 76 1t � j( C�r�r�a � )
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
6I;5 h4 ,sI e p 6n cA5 i- c 0 /
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
wf efts)
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.
)
6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED
MoKe
S I ORMWATER PLAN
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JAN 1 9 2005
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stormwater site plan template—rev.10/1/2003 JEFF O O Ty 5
DEPT.OF CO
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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.
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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.]
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11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system.
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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 wilting. 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. 0- 1
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3. Control Flow Rates.
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4. Install Sediment Controls.
5. Stabilize Soils.
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6. Protect Slopes.
7. Protect Drain Inlets.
8
stormwater site plan template—rev.10/1/2003
13. Describe the water quality system.
14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,physical characteristics of fill material,arid 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.
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17. Describe the proposed surfacing material.
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18. Describe methods for restoration of the site.
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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.
fr
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
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12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs). w.,
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12. Manage the Project. vro. d
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.004
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
stormwater site plan template—rev.10/1/2003 9
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b. Description of special requirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure).
5. Construction Phasing.
a. Construction sequence
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. V 1 P'
c. Waterways. i.) I Pr
d. Runoff/Stormwater Detention Calculations (Y
stormwater site plan template—rev.10/1/2003 10
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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.
•
(LAN NER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
2�iucJ
)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
stormwater site plan template—rev.10/1/2003 12
40
,�w1`'S�N -0, JEFFERSONIAUNTY
rti ,i DEPARTMENT OF COMMUNITY DEVELOPMENT
�' 621 Sheridan Street• Port Townsend •Washington 98368
__'�,,__ 360/379-4450 • 360/379-4451 Fax DEC 2 0 2004
qs, o www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: O"[ a
Proj�e{rq:_t_Description(include separate
sheets as necessary):
[-�► , J I�Q..( L ra r.- 2cJ
fYl li
x Parcel , Property
Number: 9(,t 5-6/ '/)3 Size: I
1L l )7frjpos��(acres/squarefeet)
•Site Address and/or Directions to Property: )m /q L <--
Property Owner(s)of Record: m r)-3ro01ers
Telephone: Fax: email:-
,,
Mailing Address: 3 old t5*�,r r\-e Q.., 1cQ / rOr(-T0�-LDn3edj to q J�X 3/i
Applicant/Agent(if different from owner): C/n d s C (hart fs, /o yl-C� C rra.( m r
Telephone: SL O- LQLP I- 19-57 Fax:3[y[) tp'l- 45`fa email:en-vile Gv Cats ckrorral,/pr,\
Mailing Address: 1 b t cp 101 Sc%I t i rh I j.c)f 9 g 38 (o r-) ��pac t.F c. I-1 kj ku c�.l I F-ernd,tei L 1v a�4
What kind of Permit?(Check each box that applies)
'Building ❑Variance(Minor,Major or Reasonable Economic Use)
❑Demolition Permit 0 Conditional Use[C(a),C(d),or Cj**
$'Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
)S Manufactured Home ❑ Boundary Line Adjustment
❑Modular ❑ Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑Change of Use 0 Long Plat**
XAddress 0 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
0 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 C,3fiC.-•COY-rod tC_ to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE U`(r _ Date: ( c 2 0
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 and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: Alt (! Date: / Dee Zc o'4
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 res sibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date: / / C ZoOy
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
•
OWNER BUILDER STATEMENT •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
reThRal Cr,l-c 1 fir, II (360 )Co6ol- 1051 (31.6 )Lo 8l-ti a
MAILING ADDRESS: 377.5. I p/��Gcr+'l cnr ao l,a-.f oail EMAIL: CA aG.0 ®COc..kLorral.CO h-..
CONTRACTORS LICENSE tbrc.re-trtiniou 1. 7R- Cr 75.33 WAJNS
NUMBER: Coocfl_..)0J1/./uJ ANp it la (OS NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
iia. New ❑ Wood Existing: 1- ❑ Sewer
❑ Addition ❑ Steel Proposed: / Bank ❑ Community System tff J
❑ Alteration/Remodel ❑ Concrete Total: Z Height: Jiit Individual System
❑ Repair ❑ Masonry SEP Permit# %-37 _
❑ Demolition ❑ Other. Bedrooms: Water Supply:
Existing: 3 Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: - / vt Public
Total: 3
�" pang Name of System:
If this is a Commercial Protect 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 1
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: 500
❑ Heat Stove I 1 Cook Stove 0 Woodstove ❑ Fireplace Insert ❑ Hot Water Tank 0 Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home? "1) No
When applying for a permit to Install a propane tank you must also su. it a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only
Current Proposed Amount
Main Floor Consistency Review: r--)
2"u Floor Base fee: i 1
3t0 Floor Additional Section: ___--__
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee: 5
Other Unheated 911/Rd Approach fee: l
Garage/Carport TOTAL: $- I
i
Decks �� l
R.caipi Number: C9C6B 6 L____
Other cast k Number: .�G
ESTIMATED COST(REQUIRED) Dabs:: `a f /04
•Fair market value of all labor and materials foundation to finish 2004
2 0 J !
initials. DEC.
G:\PemritCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc