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HomeMy WebLinkAboutBLD2005-00141 CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD05-00141 SITE ADDRESS: 61 GUN CLUB RD Issue Date: 05/25/2005 PORT TOWNSEND, 98368 Final Date: 5/15/2006 APPLICANT: BERNT P ERICSEN PHONE: 360-385-4281 MARLENE J ERICSEN 2323 HASTINGS AVE W PORT TOWNSEND WA 98368-9286 SUBDIVISION: IRVING PARK ADDITION Block: 23 Lot: 8-10+ PARCEL NUMBER: 963302304 Section: 16 Township: 30 N Range: 01 W PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: R-3 TYPE OF CONSTRUCTION: 5-1HR SPRINKLER SYSTEM ye no ) THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 5/15/2006 Cot-a- -riC I A L Q0k, ildi ficial nature Date I:\F_BLD_Occupancy.rpt 10/29/19 • BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD05-00141 Received Date 03/9/2005 SITE ADDRESS: 61 GUN CLUB RD Issue Date 05/25/2005 PORT TOWNSEND, 98368 APPLICANT: BERNT P ERICSEN PHONE: 360-385-4281 MARLENE J ERICSEN 2323 HASTINGS AVE W PORT TOWNSEND WA 98368-9286 SUBDIVISION: IRVING PARK ADDITION Block: 23 Lot: 8-10+ PARCEL NUMBER: 963302304 Section: 16 Township: 30 N Range: 01 W CONTRACTOR: REALITY HOMES INC PHONE: (253)926-6330 1308 ALEXANDER AVE E FIFE WA 98424 (253) 926-8515 Contractor's License: REALIH1984CN Expires: 2/15/2006 PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE CALL IN FOR THE REQUIRED INSPECTION41L7 IHAT APPLY TO$'$ vv UR RiJ , . SETBACKS:Ofr Pek Z A/E3 dr UFFER: . Footing: Oit 7/y�67, Foundation:L J1coPI ..-7//6/6e Stormwater FINAL Approval: 1 Underground Plumbing: Underground Insula 'on: Shear Wall : /49 2-✓ Sheathing: Framing: d!( /B*45#- Plumbing: /9i .7"�S Propane ank/ Lines: Insulation: A,P L et/0/OS G4JAc-c.s 'J4 1t...//-IS-oS' Sheetrock. //-Z. s Septic Syt m Final Approval (If not on sewer): Road Approach Final Approval: Zoning Final Approval: Final/Occupancy ApprovaK`>< Z1e t HEALTH DEPARTME4 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 tUILDING PERMIT APPLICAtON MLA05 00142 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 • PERMIT #: BLD05-00141 Received Date: 3/9/2005 SITE ADDRESS: 61 GUN CLUB RD PORT TOWNSEND, 98368 OWNER: BERNT P ERICSEN PHONE: 360-385-4281 MARLENE J ERICSEN 2323 HASTINGS AVE W PORT TOWNSEND WA 98368-9286 SUBDIVISION: IRVING PARK ADDITION Block: 23 Lot: 8-10+ PARCEL NUMBER: 963302304 Section: 16 Township: 30 N Range: 01 W CONTRACTOR: REALITY HOMES INC PHONE: (253)926-6330 1308 ALEXANDER AVE E FIFE WA 98424 9g22gg Contractor's License REALIH1984CN Expires (22552/13/2006 515 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW SFR W/ATTACHED GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,767 VALUATION 173,461.00 ADD'L: HEAT TYPE: HTP CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5-1HR SHORELINE: GARAGE: 480 CONST TYPE: SETBACK: DECK: 160 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: a/ f0/03 Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $1,408.15 BAC 03/09/05 71616 APPROVED Plan Check $915.30 BAC 03/09/05 71616 State Building Code $4.50 BAC 03/09/05 71616 MAY 2'5 2005 Potable Water Application $53.00 BAC 03/09/05 71616 Jefferson County Planning Total: $2,380.95 i Department APPROVED . ._ SITE PLAN . 6 &Lb Kit N AR - 9 2005 MAY 2 4 2005 `''` low . .....,..._ . .__�.,.. _; .,_�.... :. .-._ ._ \ JEFFERSON COUNTY Weer rwt4-a- DEPT.OF MUN TY VELO ENT t ( IY f t SIGNATURE 4- - 3 31,7b i' ` oh, �°` I II 1 lob !a ILj t i2-0 r Et. I- yam,, e too' lob q 0a4v� veyp^ u'�su9 t � 't� „ti itoo .4 y -' \ I �`P er n .44 L0 _} .,,e '., I ' :41e a • a\ ,i, i H �- is mew - ,If � � 1s � el-2-2" // . >T2 � Sri$ C ��7, ni 1 Catealt, ,N .r i --, — _ _ I fi cC zlq.ki��n.� R Q rMiwf��SZrVt. E14, MP/ % 3 bG in _ °coo It t i I TO m reser�1� q h _ ii 0 I EL, 2_, 7,2e. i Vi ic t ��j p 54'1,5 55 i `{ FL, 2 ) S14 io410 -Deck to 11 �� A5La38 4•1 i StzZ Si21 1d�Q �. /tsc.a3A --- - - _ �l�► - ,�9Rt�u'�tL. v -r�-`s'c rah A s+.aill rz. aS.rfj,+ i t• a. .2.25.40 --, _ 134,as X i5re, = 7,1v s6. . , r .4tfm Ate-ff. to S -►o , 1310c.fi- .23 irVtM P 1170 . ll%._ Mu 1 1. 4zS 1 11 wa- .01 -032.E -1l SPECIAL CONDITIONS FOR CM t BLD05-00141 • 1.) 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. 2.) 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. 3.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 4.) 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). 5.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 6.) The building height is not to exceed 35 feet. 7.) Minimum setbcak from edge of Gun Club Rd right-of-way is 20 ft. Minimum side and rear yard setbacks are 5 ft. • I:\F_B LD_Perm it_Build ng.rpt 10/29/19 iffr1JEFFERSON COUNTY 114iko. '� DEPARTMENT OF COMMUNITY DEVELOPMENT �d ). 621 Sheridan Street • Port Townsend • Washington 98368 NOD 3/7 http:/www.co.jefferrson wa.s/ommdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# v PROJECT/APPLICANT NAME: • Bzry Otte I ��- I E.V,i c-art-: 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. 4014,;i- "}`D Sl f 01 50.-4-11 Vye:C '{ '✓'�.Ibti7 c'( 7v i�pi�` ( rll t....t d-Zvat ) tIY °Gt5 +l' re,-vt.,;. dV&t AL-6(� e`v'�it 4 .+� :;�cK . �^F h��s ���se-I1 �t(1,tr.;%cl- "I(; rZs~11f:.1:4.13-1.41404,- �►�;� (,d iAA FAQ 4 iz ezE c-‘ cdvivl:e at rl 44,1-ak Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. f rc p-..e 41 e r{s fS k�r fr Nk. ,20 �Ev1 i �t tale. wn r �f6 i�1 S'1'r A.'�v i�. vt/e s LC So 5�.VV�a�S SL)4 fI -14-11 , it06 J - IY�z.�t-t1r.?4 ti't 1. 141111 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. t}, -tc tab - v i a -l '" 3 ai aye- 74z h01.4e e cm-W.1 m“->-f c�-r.. 460' .bi-tz4•. . n hwws, . re ir's semi- t&t yelt: erg bu.d r 4LiA'nfi t��.1 (4.4 'R iu � c f 4-.4:�+� 4. Describe the existing soils. Indicate soil type on the site map. S; l;n rH Gn '{ Lis Let , OL--rnti 541445 f i ILZ. S lut S C T y 4> 14-r-ei-41-( k 4147CviL. %L 4,.. ct l J,vi . SI 11c1azv IY tore - ru✓ X i/b (nyei ) °1 gti's:r' i.'ii014;s6 r"rlta' 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. tirLi c et,j4a:a.L 100v--4411Aurn 1c3G r a?. A v-n l' . 6. Describe any excess levels of noise generated by the proposed use or activity: _ _ �1ane h -I, LA t t,}L L r►t 1,N^S.�Y • Ls STORMWATER PLAN stormwater site plan template-rev.10/1/2003 �..�..r..+r JEFFERSON COUNTY DEPT.OF t 4tLOP NI SIGNATURE: 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. ri ilia. 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.). ccLf96vL Sr, , i�,) iv4vi-Gtu:cSi: ni.ec c F 'WI L.t+. z-3 I rd�nv 1"0i'rtttC2Lt'L6Y‘. I L 1s be ike.,d� ,.. ll ere,. kh 4�Zw-t CL� R .. iA),,.,r f� f�,s�.,;t,v�� (.�:.�:., Thr. r��-� of 't�2lci+i- 2� t �s �c ty+�:f- U t,.: i,,ltL,.i's 41; b1.1t/._ 3 s Y Yi_ h.wv>. xv-- itu}r,- (L ._ 5. -1kt.ri,,b m i j,t e i- �� be r t > ti*� �5 c�F., c 1 ;ri., I)) . .5z '• 'Alta, 2-3 r7 A e✓r''c, t-'q Is,� de:<<,u i n..:y► 5 4 (pa.,,64tc.. . 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. ` >tin „Dr :xs `t� Ea I rs_vw .0'c oviv 1►'t i `C� YYA: ter •-1 re...v-cbi , (irt t,r_t e.1 'v t$ke -E-tot: t:' i,tkp ►1 te-+tAk. t.i0e i.: r.t-,-, 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.] 1%Itl- 11. Describe the performance goals and standards applicable to the project. 1jIA 12. Describe the flow control system. r:�, �i xaa nv. r.,. - .. ,,.max.• .. :..j..�»r .... c 1 } A, N a 3 # 6 fs f stormwater site plan template—rev 1ikk/200.9 OM .,N; i t n d x ,9•Q i i . .r -.-ah-r� 13. Describe the water quality system. yt ,,t t'V 6t 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. .-Pl14Vl,.4 i'&o c' rj, -h Y civi '1.4,.4;,( i1tt iAre` i ✓ occ e I t,,,i • 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. (AA.e2�e 5i;:a;OttLV'.- 4 a.4ai,e, 0-ev. i✓` ` -e d 41. ..Kd [C tr6,Ylct e, et t'-r Zt c C- Iro 18. Describe methods for restoration of the site. (1 u.-bc d.4-t4 t>•'. 5t z{j 1,0 vf'� /Irc.. S _t neuf w (2 b tv(1�_ ,Gut,✓ 55 t'a¢ 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. L111- 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. N/P- 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 re t 'ctions here. IV( r. stormwater site plan template—rev.10/1/2003 7 CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential development. SECTION I—CONSTRUCTION SWPPP NARRATIVE 1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page 2-15). 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. • CLIA mu.V it, eP011-v tK !l nu:�'� UX(J ck.by [;lam t T tt.v,• 2. Establish Construction Access. ,r 1.14 w 1 z Cs `ek v n- re . W, 1 tt.ti't;.rY., -ID CZ2.[) c,Cii f(_ 3. Control Flow Rates. 4. Install Sediment Controls. J1 1.4i�r`Y 1 �i'1 53a✓r. .__ 5. Stabilize Soils. N 6. Pr test Slopes. 7. Protect Drain Inlets. stormwater site plan template—rev.10/1/2003 8 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). 11. Maintain Best Management Practices(BMPs). Witt Mt Yt t--t-Dv- q yT -ef far v It cn-t. ,1 -e tck 64irs' 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). Vth G'l t t)In LAW rDa_ ut2, • b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). ti!t 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. V yVe di•t% Yl. 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). sJOvte, 5. Construction Phasing. a. Construction sequence ( (-.izv (r,; c nor vac. ('e►t�tv � r �i try:it�, &,r• C CL,v Q.ften .• V" { eNA.A-C d.tP�': 11� &R-(4- • -U.i...Qiz.:i•li:-� �r;-t►�� b. Construction phasing(if proposed) o2.t-¢• 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. n Provide a proposed construction schedule. +v j 1 C lr �V tllt t -b 1 �C IL i K ,Ll.�t'• S�Ec; ,.,- iV1 at,� cv 7 fit.. 6-0if4_:4-e yvDJt2 l/k, J II. Wet Season Construction Activities. a. Proposed wet season construction activities. iv • b. Proposed wet season construction activities for environmentally sensitive areas. OR- 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. I h rtk CArt t'r->e iN 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. fr I r+ b. Diversions. c. Waterways. (t d. Runoff/Stormwater Detention Calculations t stormwater 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 shr submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, re drawings showing any structural changes,and any other supporting information that explains and supports the reason for the char Final Corrected Plan Submittal If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source contrc (not standard on-site stormwater management BMPs), the applicant shall submit a final corrected plan ("as-builts")when the p completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the pi constructed. APPLICANT SIGNATURE By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein i correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and col owners of the affected property. (LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: Storm .. stormwater site plan template—rev.10/1/2003 �w�'S0N cow JEFFERSOlt • ' ro DEPARTMENT OF COMMUNITY DEVELOPMENT V 621 Sheridan Street • Port Townsend •Washington 98368 — 9 2005 360/379-4450 • 360/379-4451 Fax h R O� www.co.I efferson.wa.us/commdevelopment �`3:17NG� . . Master Permit Application MLA: 450 . - )4Q Project Description(include separate sheets as necessary): 3ia i, biP r m /76'1 . , h cm�-, w� . a achk 4(1.'aye. Tax Parcel Property , • Number: Y to 3 66 3 6 4 Size: / ,f,,2'L j,:56 y p.ili 642., (acres/square feet) Site Address and/or Directions to Property: 61 .(311-n_ _e„t IZi _ ?2rt Z jj1) . ' y 3�b, Property Owner(s)of Record: ,y A+ 4 1yl,t.,,I i'4, E t ii,Se rt `I Telephone: 'SG9D'3gr5._ 4:281 Fax: 360 -3g5"-6/30 email: (xi:7eric-sr a: (' l{lea,eeo Mailing Address: ).3 L-3 444$Li s ftike. tu}u51 F6Yt, it u%Y1, r ,- , eN,36g Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) 143 Building ❑Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj** IQ Single Family ❑ Discretionary"D"or Unnamed Use Classification Garage Attached./Detached ❑ Special Use(Essential Public Facilities)** ❑Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑Change of yse ❑ Long Plat** ❑Address ❑ Road Approach dew, ❑ Planned Rural Residential Development(PRRD}/Amendments** El 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: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit I further agree to provide access 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: slailifj � A ,-., Date: 1 I t--t) 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-trans ble respon . lity for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: t el-e1/\/ Date: 1 - l 5 --d 5 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: 1Ze tu'-,i Howtt:`>PHONE: FAX: l ii_..)ti? r\1,z,rt-cwti»r Ovt? E' . 1, , (..•:-)11- 9e971 (Zy3 ) 924,4,33r (Z53) `'tZic, 937 MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: ILEA L-.1_vU_ cl C,i.-i C ti 4xF'ggti NUMBER ARCHITECT/ENGINEER: S Avv Z PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: � _ New Sr Wood Existing: ❑ Sewer ,,( 1, ❑ Addition ❑ Steel Proposed: 'f^. — Bank ❑ Community System1()Y-, ❑ Alteration/Remodel ❑ Concrete Total: 2 Height: )M Individual System ❑ Repair ❑ Masonry SEP Permit# Li Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: A. Public )'i.: by ry Total: N me of System: (s{ y4 \ ©rt% 'lek0n-sc'r If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: ❑ Underground Tank ❑ Above ground Tank Size of Propane Tank: ❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage ,For`Office'Use'Only .` 1 -. -. `q Current Proposed Amount a r I Main Floor Corts�y Re `z a iT417 i`�` 3 I : s 4 g NU f ,._ 2 Floor Base fee: , r_ I S . ! 3`0 Floor Additional Section: ' -- '.' Mezzanine: Plan Check fee: ' '" ( c . ,, Heated Basement StisdeA reNirge:fee: `' `, ;.-R c�i1 Unheated Basement PO Water Review fee: c,-i Irk Other Unheated 911/Rd l Approach fee: kit. c '' Garage/Carport �// + x ., a �- ' ?g0 I l . 13 TOTAL $ . f '' t r • Decks .��#...,:, t,�p ^ `; i6U Si 1I 40Receipt Number: 4� ;r Other Cash/Cbeck Number ESTIMATED COST(REQUIRED) Date: 9 2005 5 4,-- ,�, !: •Fair market value of all labor and materials foundation to fin' r. A' €, :41i 5� 000 . +� l i(„rnitials• - n , ofr. ` a G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.d.c