HomeMy WebLinkAboutBLD2005-00026 • .
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 #: BLD05-00026 Received Date: 1/13/2005
SITE ADDRESS: 186 1ST ST Issue Date: 2/9/2005
PORT HADLOCK, 98339
APPLICANT: DARYL HEDMAN
C/O 261533 HWY 101
SEQUIM WA 98382
SUBDIVISION: IRONDALE HEIGHTS LONG FLAT Block: Lot: 11
PARCEL#: 962900011 Section: 2 Township: 29 N Range: 01 W
CONTRACTOR/ PRESTIGE PROPERTIES PHONE: (360)681-3094
DEALER 261533 HWY 101
SEQUIM WA 98382
Contractor's License PRESTP1066CM Expires 1/18/2007
INSTALLER: JAIME KOZELISKY WAINS0626 Expires: 7/31/200;
1112 S JACOB MILLER RD PORT TOWNSEND WA
98368
PROJECT DESCRIPTION: NEW MANUFACTURED HOME
MODEL GE664
MAKE: GODEN WEST
YEAR: 2005
SIZE: 56 X 27'4"
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 2/9/2006.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): `/"7/:
Stormwater FINAL Approval:
Blocking/Plumbing: `//Z0S
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps,, 6 v
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
• S
SPECIAL CONDITIONS CASE # BLD05-00026
1.) The road approach permit (RAP05-00017) must be inspected and finalled by the Jefferson
County Department of Public Works prior to the final inspection/certificate of occupancy of
this residence. Contact Terry Duff at 360-385-9159 for the road approach inspection.
2.) The application was reviewed by the Jefferson County Department of Community
Development for the presence of Environmentally Sensitive Areas (ESAs). The
Department conducted a review and has concluded that the property DOES NOT contain
Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA
review and conditions may be added if new ESAs are found on the property.
3.) The applicant is proposing to create or add 2,540 square feet of impervious surface and
6,500 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.
4.) 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.
5.) 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.
6.) Stormwater shall be retained and infiltrated on site. The owner shall control all
sedimentation and erosion on the property.
7.) The revised site plan as submitted on January 24, 2005 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 February 9, 2005 shall be resubmitted for review and approval
by Jefferson County Department of Community Development.
8.) 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.
9.) 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).
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, buildings only, is not to exceed 60%. Adequate space must be
provided for required parking, setbacks, landscaping, utilities, septic system (if no sewer
available) and stormwater management facilities, as applicable.
13.) The building height is not to exceed 35 feet.
11°
•
14.) Setback from 1st Street right-of-way is no less than 20 ft., setback from S. Maple
right-of-way is no less than 20 ft., 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.) 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.
16.) 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.
17.) A minimum of two (2) on-site parking spaces is required for the single-family residence.
18.) This parcel was created through Irondale Heights Long Plat under AFN 433898, recorded
May 23, 2000, Volume 7, page 131 - 132 with the Jefferson County Auditor's office.
19.) The parcel is a legal conforming parcel designated Urban Low Density Residential (ULDR)
through the Irondale & Port Hadlock Urban Growth Area Zoning Map effective August 23,
2004 as an amendment to the Jefferson County Comprehensive Plan Land Use Map
effective August 28, 1998.
20.) This parcel is served by a public water system.
21.) A septic permit (SEP03-00194)was approved August 15, 2003 for a capacity of 360
gallons per day.
22.) First St. (C638209) is a county local access road A road approach (RAP05-00017) was
approved on February 9, 2005 and an address of 186 First St. has been assigned to the
parcel.
23.) This parcel is located within the Optional Sewer Service Area as shown on the Irondale
and Port Hadlock Sewer Service Areas Map effective August 23, 2004 as an amendment
to the Jefferson County Comprehensive Plan.
di
MLA05-00021
•UILDING PERMIT APPLICATION Review Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00026 Received Date: 1/13/2005
SITE ADDRESS: 'Oci 1ST ST
PORT HADLOCK, 98339
OWNER: DARYL HEDMAN PHONE:
261533 HWY 101
SEQUIM WA 98382
(360)379-1643
SUBDIVISION: IRONDALE HEIGHTS LONG PLAT Block: Lot: 11
PARCEL NUMBER: 962900011 Section: 2 Township: 29 N Range: 01 W
CONTRACTOR: PRESTIGE PROPERTIES PHONE: (360)681-3094
261533 HWY 101
SEQUIM WA 98382
Contractor's License PRESTP1066CM Expires 11/13/2004
REPRESENTATIVE: DARYLE HEDMAN PHONE: (360) 379-1643
261533 HWY101
SEQUIM WA 98382
PROJECT DESCRIPTION NEW MANUFACTURED HOME
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,512
VALUATION ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Floodplain
Routing Date: F&W Landslide
i
l /o Shoreline Aquifer
( Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: !'11plo=r V E
Permit $157.00 BAC 01/13/05 69111
Potable Water Application $53.00 BAC 01/13/05 69111 FEB - 9 2005
Total: $210.00 Jefferson County Planning
&Building Department
-40 •
iE11' AN UI Jciterompa County Comrtasoopr
S II. 1220, Port Tovrawrool, W IlS3411
1300)385-siss
MOBILE HOME INFORMATION FORM COPY
0TYP"7::str SI 11%!)*1 E/MAILING ADDRESS:
r DARYLHEDMAN / (REBEKAH WOLFF - BUYER)
CT' -7-57 61333 HWY 101 , sequim, Wa. 98382
Arg)„ -
i;• 771-' mew 14 this questionnaire is to obtain information regarding either the
- • nfl' a mobile home or the previous ownership and location of a me e
- AtilSdU ;help our office determine whether the mobile home is already on
1:1 !I I la 0 ediersou County or if it has been moved to this county from another a
7 11" 1,1,r.ri: DATA:
u,16 GOLDEN WEST HOMES mommyEL GE564 (c)vEAR2005
eri)p E1-C1'11 56f t (E)WIDTH 27 ' 4" (F)SERIAL#
75 000-
' ' CTIASE PRICE (Do not include saleo tiuc) ' PURCHASE DATE3-15-05
5'1 ,135, 1:11/7/aEll/LOCATION OF MOBILE HOME' (IF NEW MOVE TO QIJESTION
:FROM C171101,1 DID YOU PURCHASE MOBILE PRESTIGE PROPERTIES ,INC.
TESS 261533 HWY 101, SEQUIM, WA. 98382
P ify1{13:1LE ROME ASSESSED IN JEFFERSON COIJNFY LAST YEAR?IT,AbitX
NEW
Yen.Previaus address of mobile.
NONE
J11 N. What Count y was Mobile assessed in last year.
;ROME IS TO BE LOCATED:
VIP 11,'Mt MOBILE HOME BE IN MOBILE HOME PARK? XXAX
!IF I WAVED IN MOBILE HOME PARK:
liAE el ADDRESS OF PARK Lot/Spakee
., TE1P IN MOBILE HOME PARK:
qiIT OTF LAND OWNER.t
LOCATION ADDRESS
".. .7.3Y9PERTY PARCEL#/DESCRIPFION
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arkk,...). JEFFERSON COUNTY ,
`a►�I DEPARTMENT OF COMMUNITY DEVELOPMENT
I
lip ,. r 621 Sheridan Street • Port Townsend •Washington 98368
O 360/379-4450 . 360/379-4451 Fax
http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# ra J rr � //// / "
"y 1 PROJECT/APPLICANT NAME: r2 G-C•la" �'L cX I ��s
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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.
Existing Conditions Summary
2. Describe the existingg5- topography. Indicate contours on the sits
� map. //
` � ,�--<•- Z,�,.l;,T r (--V-7 6 L--4 -�ti--- AL.7.rG ...�s--Z./c--3i1-e_ 4,-1.-- ,-.16.4-c,"
,-1--, L,.;. .. " 'Z s "Ai— Gel"A-e
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3. Describe the existing vegetatio dicate native vegetation areas on the site map.
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4. Describe the.existing soils. Indicate_soil type on the site map.
---,.---442-2--"-) ,z (-----c."_, .4-2-r7A------ :‘,„ ..„.4,..„,._e,e 7.„..,,,,,...„,e, -
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 _
STORMWATER -PLAN
FEB - 9 2005
stormwater site plan template—rev.10✓1/2003
5
JEFFERSON COUNTY
DI PT.or C 1 MENT
SI(i NATI IRE.-,tr " V
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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.
1 .
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.]
11. Describe the performance goals and standards applicableto the project.
12. Describe the flow control system.
LAN 1 3 2005
stormwater site plan template—rev.10V1/2003 ;z 6
I
13. Describe the water quality system.
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of xcess m tenal. -
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
L.---t,..,-, . C1'....e.A....-...9°(-1--i-10.:ece.--
17. Describe the proposed surfacing material.
18. Describe methods for restor tion of the site. f/
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' 7-teem -ri,_,•-- L-,,, -1-1.-4-e..2-•-i..--,..> ,1 4...//7 .-
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.
L--)-1:-/lie__'' -
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
. z/7 _
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.
)/..4 , _ ._.
l; - -�iiv']
stormwater site plan template—rev.10/1/2003 7
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) r
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 1
2-15).
12 Required Elements-Construction SWPPP
1. Mark Clearing Limits. ,' ., /;
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— 7- -f.. 47 1.�e9,'1,e....C7e, "✓e-17'L 4'L-4.Z`2'4,,-s
2. Establish Construction f", ss.
!ale--. l•---;:-Z-1-17,-;:e/—/9---i-s-‘e-c-L.---e-L7- 2-4--)/1"--4-z---Gz--;€,--..----
3. Control Flow Rates.
4. Install Sediment Controls.
5. Stabilize Soils.
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6. Protect Slopes.
7. Protect Drain Inlets.
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stormwater site plan template—rev.10/1/2003 8
or: tl 1
4
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
9. Control Pollutants.
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
n
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).
r
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.
i I
l j
stormwater site plan template—rev.10✓1/2003 .- 8
b. Description of special requirements for working in or near environmentally sensitive areas.
/// i;•
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)
- r J_5 5
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule. ,
-l c.;-6
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for environmentally sensitive areas.
7. FinanciaVOwnership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Describe bonds and/or other eGidence of financial responsibility for li ty 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 (;
7 b a 3 2005
e
stormwater site plan template—rev.10/1/2003 r 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.
(LANDOWNER OR AUTHORIZED REPRESENT E SIGNATURE) (DATE)
EP
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED:
I
JAN 1 3 2005 f r •,.
stormwater site plan template—rev.10/1/2003
� O2v cO� JEFFERS_ (1NTY
A DEPARTMENT COMmutin ti FLOP�MEN� ,,' j� i r,, - ".4. - .
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621 St>endan Street.Port d'•Washington 98368 ] ' ` : . .
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.y 360V37941,50. -360/3T9-4451. `
.4, N��o www.coffersonwa.usJconurtdl�a�eiometIA�1 i 3 2005 • .
Master Permit Application "° MLA:E 0 5 ZJ
Project Description(include separate sheets as necessary):
TO INSTALL A NEW MANUFACTURED HOME & UTILITIES AS REQUIRED
Tax Parcel Number: 962900011 y
Size: 1S , 750
(acres/square feet)
Site Address and/or Directions to Ply: 182 1st- STRF.FT PORT PADLOCK, WA.
PropedyOwner(s)of Record: DARYL HEDMAN, IN ESCROW TO REBEKAH .WOLFF
Telephone: 3 7 9-16 4 3 Fax email:
MaiTingAddress: 261533 HWY 101, Sequim, Wa. 98382
Applicant/Agent(if different fiom owner):LOWELT, MATTHEW PRESTIGE PROPERTIES .INC,
Telephone:360-681-3094 - Fax 360-681-3098 email:
Mailing Address:
What kind of Permit?(Check each box that applies)
XiCBrifdrg 0 Variance(Mnor.Major or Reasonable Economic Use)
0 Demolition Permit O Conditional Use[C(a),C(d).or
0 Single Family 0 Discretionary-0-or Unnamed Use Classification
0 Garage
edA&Mur Attached
h /Detached0 Use(Essential Public Facilities)**
0 Boundar0 Short Plat Line Adjustment
0 Modular
0 Commercial* 0 Binding Site Plan"
O Change of Use 0 Long Plat"
0 Address 0 Road Approach O Planned Rural Residential Development(PRRD)Amendments"0 Propane 0 Plat Vacation/Alteration'•
0 Mowed
Y "Use Consistency
Managemen Analysis alysis 0 Shoreline Master Program Exemption/Permit Revisions"
0 Shoreline Management Substantial Development"
O Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
0 Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
0 Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
❑Forest Practices Ad/Release of Six Year Moratorium
'May require a Pre—Application Conference "Requires a Pre-ApplcatIon Conference
Please identify any other local,state or r federal permits required for this proposal,if known:
SEPTIC SEPT 03-00194
I hereby designate ` DESIGNATION OF AGENT
: to act as my agent-in matters relating to this application for permit(s).
OWNER SIGNATURE
nE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and aonect 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. .4
I further agree to save,indemnify and hold harmless Jefferson ` ,
may Y way accrue County against all Gabtiities,judgments.court costs,reasonable attorney's fees and
expenses which in anagainst 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
review and any required later of entry to this properly shall beagents the sole purpose ofb application
haws. � v�'�� requested and shall occur only during regular fxrsines:
Signature:
"``''�� Date: / / /; 0'
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. My individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
actions)even if you are incompliance with the Jefferson County development code.The Applicant acknowledges
and non-¢ansf- responsibiG that andhe,she or and holds individual
e ) complying with the ESA. The Applicant has read this dlsdaaner
Signature: ``,,,,/ / / signs dates it below.
-�-- Date: / '"//— c�
G:\PeunitCcnter\FORMS\DRD FORMS\Master Permit Application 74-04 doe
OWNER BUILDER STATEMENT 1°., ',.
The signer of this statement does hereby certify that th y are the Owners of the parcel referenced herein.that are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.•-
Signature: oat'."0 6. 0 3 , .; P.'ti, - . ,
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE:• FAX:
PRESTIGE PROPERTIES INC. ( 360) 681-9034 . ( )
MAIUNG ADDRESS: 2 615 3 3. HWY 101, S e q uim W& 9 8 9 '
CONTRACTOR'SLJCENSE WANS_KOSLISKY'-'HOME SERVICE
NUMBER: - PRESTP I06 6 CM NUMBER
ARCHITECT/ENGINEER: PHONE ( ) Fax:( )
MAILING ADDRESS: Eta
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
NiK New v,,� Wood Existing: -0- ❑ Sewer
❑ Addition "' ? Steel Proposed: 2 Bank 0 Community System fq,\ ?'
❑ terat oniRemodel O Concrete Total: ___2____ Height VInd victual System
❑ Repair 0 Masonry SEP.Penult# 0 3-0 019 4
❑ Demolition O Other: Bedrooms: -0_ Water Supply
T of Heat Existing: Setback: ❑ Private well . 0 Two Party`l
Proposed: _ �� Rv.
ELECT. FORCED AIR Total: " Name of SystemPUD 1
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:tion: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all Items below that apply:
❑ Underground Tank 0 Above ground Tank Size of Propane Tank:
❑ Heat Stove ❑ Cook Stove 0 Woodstove ❑ Fireplace Insert ❑ Hot Water Tank 0 Pellet Stove ❑ Other
Is this appliance being Installed In a Manufactured I 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. V
Square Footage F i, f'tcegJ f'- ;�1"4 + > '�,; R< ugi _" M� i
Current Proposed F. t...4' r k Zm-0; n'�'� �. i '�J a ,.Jt Rz
Main Floor .., .i� , <rr ',,4J 011. . ' ;,,A,
1512 5 ,li` `fs'� -�- , fir, ��jco
214`)Floor .4tX ^!.�' st $.sa' "� Ar }}�� �.z ,' t,'''.r��,. � •• x 11..-.' ,'/J k.,-
. ,�-� Ly .^ ` .. , 11.E ',s.,,s T',L- J 2/'1/l./
3`°Floor "-- .N , .5 �` F 5" . ;�R"og.Wk {rw � ' -'#5,
.: ...� 'i 1•47, '. ..�. A1i Y A,� L' V}': '�nMpI ,:S 'lam Y`
Mezzanine: ,? i r s s � 3'? kF :4,k1�t ;Sx- �;yy�.
5 l ;' ,yk.� @; ..4r �'- _.hR',h..}� F'. -�.. ss !t. ,I N`�c s`,ter_ '. . ,,. t `7:
Heated Basement �'� :i.. It l ` r * 'i
Unheated Basement �y� `• �'
n
.I .,, y sf t � t yy,,,,,,� Ye� it r -- .t ,t4., 9:`s '•'r .r:'
.} t M, :t.i#f .'T- "�z- �' a,a'F9 a3,'4 k+ .7r, '-�. - '+fie 1.2i.. -� .•*. I. r i
1 5" t[�� L�' 4t I Y�y•
` .TF.Ji"-4.' -:iL'0. '1' Y• 3.m.q
Other Unheated " {i • y' T t., '.. '
-5 .-r- -x • d,r
}hut} K.,•: 4's1 ., .ic4 L .fF_.C'.. t �b tw.rz° - -Y+e- fir,. a
Garage/Carport y y-h "x 4,�e �4
�r 't�L..r 4- t ~ Yr.'cv fL !F yar .�3
Decks e .i ,_ ! Y 1X.11,1h ' T�s-4-j fiii�h�tf .f4, %tY4l :,':a r(ice/;//
Other .:-.41,,, , j. � „„ ,.f.,;, ! cJ aSn ,•
,.. /y,,,
1. :y 4. fi . eft; 1. -•�yc .�°� � *.tic. `e'-t.'�. /'' I lit
. . ..r,... � :.--, , .I..'. • '. ' CAS 5az)
ESTIMATED C QUIRED) '„ Y '` "�,;CA'` r xs
.Fair market value of all labor and materials foundation to finish .' \, -i.. t `-sy ,;� _ ""`{y £ 3t t 1 /�
r. +�C i-r: a ter °Y,--ek r i y',Y•y+ttlr'�. ,F T W ,4t � x...& e'z�
- r. .x' _i:f•: t. • .r. -:a.9t.,...d a-6..cT•n k'Fax 7.0-
G:\PemritCcnteAFORMS\DRD FORMS\Muter Pem it Application 7-8-04.doc
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