HomeMy WebLinkAboutBLD2005-00171 deUILDING PERMIT APPLICRAN MLA05-00171
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00171 Received Date: 3/22/2005
SITE ADDRESS: 1314 FAIRMOUNT RD
PORT TOWNSEND, 98368
OWNER: LEONA BROWN PHONE: 360-379-1663
HOPKINS/NORTHUP TR
PO BOX 927
CHIMACUM WA 98325-0927
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901192011 Section: 19 Township: 29 N Range: 01 W
CONTRACTOR: DIRT & STUFF CONSTRUCTION PHONE:
PO BOX 534
PORT HADLOCK WA 98339
Contractor's License DIRTSSC967138 Expires
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION DEMO 2 BLDGS
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2003 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date; �
7/2 "3/ per-
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $49.00 BAC 03/22/05 71574 A P P R O\ E i
State Building Code $4.50 BAC 03/22/05 71574 4►
Total: $53.50 SEP 2 6 2005
tr`efferson County Planning
f & Bpartment
• .
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00171 Received Date 3/22/2005
SITE ADDRESS: 1314 FAIRMOUNT RD Issue Date 9/26/2005
PORT TOWNSEND, 98368
APPLICANT: MILDRED NORTHUP PHONE: 360-379-1663
LEONA BROWN HOPKINS/NORTHUP TR
PO BOX 927
CHIMACUM WA 98325-0927
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901192016 Section: 19 Township: 29N Range: 01W
CONTRACTOR: DIRT& STUFF CONSTRUCTION PHONE:
PO BOX 534
PORT HADLOCK WA 98339
Contractor's License DIRTSSC967B8 Expires
OWNER, MILDRED NORTHUP PHONE: 360-379-1663
if different: LEONA BROWN HOPKINS/NORTHUP TR
PO BOX 927
CHIMACUM WA 98325-0927
PROJECT DESCRIPTION: DEMOLITION OF TWO STORAGE BUILDINGS CONSTRUCTED
OVER WATER: The applicant proposes to demolish two
abandoned buildings, removing and disposing of all materials from
the site. Building #1 is 25 ft. x 15 ft. single story wood
construction. Building #2 is 25 ft. x 25 ft. single story wood
construction with a concrete foundation that will be removed.
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 9/26/2006.
REQUIRED INSPECTION:
FinalApproval: 4464‘, � 8/4%1
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
• •
SPECIAL CONDITIONS FOR CASE#BLD05-00171:
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on July 20, 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:
Shoreline Designation -Conservancy, Eagle Habitat, Wetlands, Seismic Hazard,
Susceptable Aquifer Recharge Area (SUSC).
2.) Parcel 901 192 011 is a tidelands parcel. No zoning has been established for this parcel.
Parcel 901 192 016 is a legal non-conforming parcel designated as Rural Residential 1:5
under the Jefferson County Comprehensive Plan Land Use Map effective August 28,
1998.
3.) The applicant is proposing to create or add no impervious surface and 2,000 square feet
of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified
Development Code requires that your proposal comply with Minimum Requirement#2
(Construction Stormwater Pollution Prevention)of the Department of Ecology Stormwater
Management Manual for Western Washington 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.
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.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements#1 through#12 of the Department of Ecology's Stormwater Management
Manual for Western Washington to control stormwater, erosion and sediment during
construction. BMPs shall address permanent measures to stabilize soil exposed during
construction, and in the design and operation of stormwater and drainage control
systems.
6.) Fairmount Rd. (C503209) is a county local access road. A road approach is existing and
an address of 1314 Fairmount Rd. has been assigned to the parcel.
7.) SEPA(see below)
8.) The Environmental Checklist was submitted to the Department of Community
Development July 29, 2005.
9.) Public Notice was published in the Port Townsend-Jefferson County Leader newspaper
on August 17, 2005. Notice of the pending threshold determination was posted on the
property by the applicant/representative on August 17, 2005. Notice of the pending
threshold was also mailed to owner of subject property and property owners within 300
feet on August 16, 2005.
10.) The Notice of Type I Land Use Application and Pending SEPA Determination
(MLA05-00171)was published in the August 17, 2005 edition of the Jefferson County
Port Townsend Leader and requested comments to be submitted to the Department by
4:30 p.m. on August 31, 2005 AND that the Department expects to issue a DNS for this
proposal. The Notice further states, "There will not be another comment period after the
threshold (final) SEPA determination is made. In addition, since this is a Type I permit
application, the threshold determination cannot be appealed except to Superior Court."
• •
11.) Staff requested review and comments on the Environmental Checklist from the following
agencies: Fire District#5, School District 50, City of Port Townsend, Jefferson County
PUD#1, Jefferson County Environmental Health Department, Jefferson County
Department of Natural Resources, Jefferson County Department of Public Works,
Jefferson County Assessor's Office, Jefferson Transit, Port of Port Townsend,
Washington Department of Transportation, Washington Department of Ecology,
Washington Department of Fish and Wildlife, Washington State Department of Natural
Resources, Jamestown S'Kallam Tribe, Port Gamble S'Kallam Tribe, Port Townsend
Leader, Peninsula Daily News.
As of September 13, 2005, the following written and verbal comments were received from
agencies, adjacent property owners or interested parties:
1)Washington Department of Fish and Wildlife- Randi Thurston
In summary, her comments were:
A Hydraulic Project Approval (HPA)will be required for this project. The intertidal beach
at the project location is a documented sand lance spawning beach and work should not
be done between October 15th and March 1st.
Staff Comment: This will be made a condition for approval of the permit.
2)Washington Department of Fish and Wildlife-Shelly Ament
In summary, her comments were:
The project site is over 2,500 ft. from the nearest documented eagle's nest. There is no
need for an eagle habitat management plan unless the applicant will be removing trees.
Staff Comment: The proposal as submitted does not include removal of trees.
3)Washington Department of Ecology- Southwest Regional Office
In summary, their comments were:
If contamination is currently known or observed during construction or soil removal
(placement), sampling of the potentially contaminated media must be conducted. If
contamination of soil or groundwater is readily visible, or is revealed by sampling, the
Department of Ecology must be notified.
Staff Comment: This will be made a condition for approval of the permit.
4) Property Owner- Leona Brown
In summary, her comments were:
Project requirement. My pavement drive way and septic line has to be protected before
crossing with equipment. Any damage done must be repaired within two weeks after
work is complete.
Staff Comment: As owner of the property, the applicant is responsible for ensuring the
work is performed properly and in a timely manner. Her comments will not be made a
condition of approval.
12.) Development Review Staff conducted a site inspection on September 14, 2005.
• .
13.) Summary of Significant Environmental Comments: This section is intended to
supplement the applicant's environmental checklist with information from Development
Review sources and comments and to analyze the proposal in order to identify potential
environmental impacts. Information available in the environmental checklist is not
repeated in this document unless it is necessary to do so as part of staffs analysis.
EARTH: The area immediately behind the structures has a slight slope and is vegetated
with grass, shrubs and a few trees. The site soils are mapped as Coastal Beaches (Co)
in the Soil Survey of Jefferson County, Washington (August 1975). The soils are
described as consisting of sandy and gravelly sloping beaches long, narrow strips.
Coastal beaches have no vegetation and are subject to continual wave action during high
tides and storms. This land type is used for clam and oyster production and for
recreation areas and wildlife habitat. This land type is not suited for crops.
Comments received from the Washington Department of Ecology are as follows:
"Toxic Cleanup: Chuck Cline (360)407-6267
If contamination is currently known or observed during construction or soil removal
(placement), sampling of the potentially contaminated media must be conducted. If
contamination of soil or groundwater is readily visible, or is revealed by sampling, the
Department of Ecology must be notified. Contact the Environmental Report Tracking
System Coordinator at the Southwest Regional Office at (360)407-6300. For assistance
and information about subsequent cleanup and to identify the type of testing that will be
required contact Mr. Chuck Cline. If contamination is identified, this issue may be
referred to your jurisdictional health department as a solid waste concern."
Sections 6.6 and 6.7 of the Jefferson County Unified Development Code require the
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington 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. Based on the
applicant's compliance the department finds the proposal is not likely to result in
significant adverse impacts to Earth. Additional analysis of the proposal and its effect
related to Earth is not necessary.
AIR: The SEPA checklist stated, "exhaust emissions resulting from machinery used to
dismantle the building and vehicles used to haul debris away and deliver gravel.
Operation is expected to last 7 to 10 days". No significant adverse environmental
impacts related to air have been identified. No mitigation measures are proposed.
Additional analysis of the proposal and its effects related to air is not necessary.
WATER:
Surface: The SEPA checklist and GIS mapping show the proposed project is located in
Discovery Bay. This area has a shoreline designation of Conservancy. The comment
letter from Randi Thurston (WDFW) states:
"It appears from the description of the project that a Hydraulic Project Approval (HPA)to
be issued by WDFW will be required for the project.
The applicant should allow 45-days from the date of the final SEPA Determination for
processing of the JARPA and plans for a HPA. However, most HPA applications are
processed within a couple of weeks of receiving the final SEPA determination (complete
application).
The intertidal beach at the project location is a documented sand lance spawning beach.
As a result, the work should not be done between October 15th and March 1st."
The SEPA checklist indicates approximately 25 cubic yards of glacial till gravel will be
• •
spread over the footprint of the buildings after removal. All fill will occur above high tide
line. All debris will be removed from the site at low tides.
Sections 6.6 and 6.7 of the Jefferson County Unified Development Code require the
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington 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. Based on the
applicant's compliance the department finds the proposal is not likely to result in
significant adverse impacts to surface water. Additional analysis of the proposal and its
effect related to Surface Water is not necessary.
Groundwater: The proposal does not include groundwater withdrawal. County
Environmentally Sensitive Area mapping identifies this parcel is within a susceptible
aquifer recharge area, however, the proposal is not identified as a high impact land use.
Refer to the comments by the Department of Ecology under the EARTH section.
No significant adverse environmental impacts related to Groundwater have been
identified. No mitigation measures are proposed. Additional analysis of the proposal
and its effect related to Surface Water is not necessary.
Water Run-Off(including stormwater): Jefferson County Department of Public Works did
not comment on this proposal. The project area is 2,000 square feet. Sections 6.6 and
6.7 of the Jefferson County Unified Development Code require the proposal comply with
Minimum Requirement#2 (Construction Stormwater Pollution Prevention) of the
Department of Ecology Stormwater Management Manual for Western Washington 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. Based on the applicant's
compliance the department finds the proposal is not likely to result in significant adverse
impacts to Water Run-Off. Additional analysis of the proposal and its effect related to
Water Run-Off is not necessary.
PLANTS: The site is vegetated with grass and shrubs. No vegetation will be removed.
Any newly exposed soils will be revegetated with native grasses. The Department
recommends finding that the proposal is not likely to result in significant adverse impacts
to Plants. No mitigation measures are proposed. Additional analysis of the proposal and
its effects related to PLANTS is not necessary.
ANIMALS: An ESA check was conducted the site is mapped in an eagle habitat area.
The proposal was sent to the Washington Department of Fish and Wildlife for comments.
A summary of her verbal comments follows:
The project site is over 2,500 ft. from the nearest documented eagle's nest. There is no
need for an eagle habitat management plan unless the applicant will be removing trees.
The proposal as submitted does not include removal of trees.
Per the comments received from Randi Thurston, WDFW, this beach is documented as a
sand lance spawning beach. As such, work should not be done between October 15th
and March 1st. The permit will be conditioned as follows: In order to not conflict with the
sand lance spawning time no work on this project shall be done between October 15,
2005 and March 1, 2006. The Department recommends finding that the proposal is not
likely to result in significant adverse impacts to Animals. Additional analysis of the
proposal and its effects related to Animals is not necessary.
ENERGY AND NATURAL RESOURCES: The buildings are being removed and will not
be replaced. No significant adverse environmental impacts have been identified. No
mitigation measures are recommended. Additional analysis of the proposal and its
effects related to Energy and Natural Resources is not necessary.
• •
ENVIRONMENTAL HEALTH: An asbestos survey was completed. No asbestos was
found in either building. The SEPA Checklist as states, "Machinery used to dismantle
structures could ignite debris prior to removal." The proposal was sent to Fire District#5
for comments. No response was received. Therefore, it would appear that by lack of
response there is adequate fire protection to meet the needs of this project. No
significant adverse environmental impacts have been identified. No mitigation measures
are recommended. Additional analysis of the proposal and its effects related to
Environmental Health is not necessary.
NOISE: This proposal will create noise during from 7:30 a.m. to 5:00 p.m. with demolition
activities. No significant adverse noise impacts have been identified. No mitigation
measures are recommended. Additional analysis of the proposal and its effects related to
Noise is not necessary.
LAND & SHORELINE USE: The parcel is along Discovery Bay. The shoreline
designation for this parcel is Conservancy. A Hydraulic Project Approval (HPA)from
WDFW is required. (See comments under WATER.) No mitigation measures are
recommended. Additional analysis of the proposal and its effects related to
Land/Shoreline Use is not necessary.
AESTHETICS: The buildings will be removed and any exposed soil revegetated. No
significant adverse environmental impacts have been identified. No mitigation measures
are recommended. Additional analysis of the proposal and its effects related to
Aesthetics is not necessary.
LIGHT AND GLARE: No significant adverse environmental impacts have been identified.
No mitigation measures are recommended. Additional analysis of the proposal and its
effects related to light and glare is not necessary.
RECREATION: No significant adverse environmental impacts have been identified. No
mitigation measures are recommended. Additional analysis of the proposal and its
effects related to Recreation is not necessary.
HISTORICAL & CULTURAL PRESERVATION: No significant adverse environmental
impacts have been identified. No mitigation measures are recommended. Additional
analysis of the proposal and its effects related to Historical and Cultural Preservation is
not necessary.
TRANSPORTATION: No significant adverse environmental impacts have been identified.
No mitigation measures are recommended. Additional analysis of the proposal and its
effects related to Transportation is not necessary.
PUBLIC SERVICES: No significant adverse environmental impacts have been identified.
No mitigation measures are recommended. Additional analysis of the proposal and its
effects related to Public Services is not necessary.
UTILITIES: No significant adverse environmental impacts have been identified. No
mitigation measures are recommended. Additional analysis of the proposal and its
effects related to Utilities is not necessary.
Based upon the above findings, the SEPA Responsible Official issues a Mitigated
Determination of Non-Significance.
14.) This is a Type I Permit decision. Threshold determinations on Type I permit decisions
may not be appealed except to Superior Court.
15.) Prior to commencing development activity, proponent is responsible for informing the
Washington Department of Fish and Wildlife (WDFW) in order for WDFW to determine
whether this action is subject to the Washington State Hydraulic Code (Chapter 220-10
WAC). Hydraulic Project Approval (HPA) is required for all hydraulic projects, which are
defined as construction or performance of other work that will use, divert, obstruct, or
change the natural flow or bed of any of the salt or fresh waters of the state.
• •
16.) In addition to Jefferson County permit conditions, the project proponent shall comply with
all conditions set forth by the Washington Department of Fish and Wildlife through
Hydraulic Project Approval.
17.) In order to not conflict with the sand lance spawning time no work on this project shall be
done between October 15, 2005 and March 1, 2006.
18.) Toxic Cleanup: Chuck Cline (360)407-6267
If contamination is currently known or observed during construction or soil removal
(placement), sampling of the potentially contaminated media must be conducted. If
contamination of soil or groundwater is readily visible, or is revealed by sampling, the
Department of Ecology must be notified. Contact the Environmental Report Tracking
System Coordinator at the Southwest Regional Office at(360)407-6300. For assistance
and information about subsequent cleanup and to identify the type of testing that will be
required contact Mr. Chuck Cline. If contamination is identified, this issue may be
referred to your jurisdictional health department as a solid waste concern.
19.) This parcel is located in an area with a shoreline designation of Conservancy. Based on
comments received on June 24, 2005 from Washington Dept. of Ecology(copy of e-mail
in file)demolition of structures does not constitute development. Therefore, neither a
Shoreline Substantial Development Permit nor Shoreline Exemption is required.
20.) Replacement of these structures would require review and permitting and would probably
not be approved.
21.) 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.
22.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
23.) 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.
24.) GIS mapping indicates wetlands associated with the shoreline. Staff conducted a site
visit on September 14, 2005 to review site conditions. The demolition will take place in
the immediate area of the two buildings. During the demolition of the buildings all
construction debris will be removed. The applicant will revegetate the area with native
plants and grasses. Based on the above, staff did not request a wetland delineation.
I:\F_BLD_Permit_Propane.rpt 10/29/19
or
,cuma uoloa 6A1. 360 491 6306 °RC?.-t
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it ill , ,,
1 . a ti�a n PERMIT*
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J �► ' a `-. APPROVED
v �� CONDRIONALLY APPI�V€D,•r,,..,..�,,, ,
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JUL 2 9 2005 ( Not APPROVED .
FOR coftllPt uNCE wrm
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Notification of Demolition Permit~
It is unlawful for any persou to cause or allow the demolition (or major renovation)of any structure unless all asbestos-
containing materials have bees,removed from the area to be demolished, Work shall not commence on an asbestos project
or demolition unless the owner or operator hue obtained written approval from ORCAA. A .,linen application for a
demolition shall Include a certification that there is no known asbestos-containing material remaining in the area of the
structure.
Project Si ddr ss: %!y .
----•'1�'�« County: •
it City:, --, State: %
`1`" ,- StartingDate: �-� �--="----Zip:—�1� 1..f.�
Li ll Completion Date: , Z.L1 r "' S' /D4d, —
L •(Therf:is a :0 working day advance notification period from receipt of permit application)
a.1t 111 �ol��' 9 a //
Property owit1G{Ie M. Brown Trust Telephone: Fax:
Mailing Address: PO, Er ix 927
-----------Ciry'— ----
— _' !i State:
n
_ Zip:--
Demolition Conactor: tr
le License#: .Pj 1 7 5 (li ',6 7
Manias; ' "--4s: 2-- e=
City._ - - —
State: � ,' Zip: 9 �3 7
Contact Person: —
elephone: ooQ--(a C) 5-3 04;f Fax: 2',49-71LQ
YES / N
"Demolition by Wrecking or Dismantling? ($25.00 fee) check# _.
_C/ T g Fug Demolition? (If yes, attach fire department request for training fire)
--_ enovat-i n,Alteration,Remodeling,Maintenance, or other Construction?
Asbestos found or suspected*
*An ORCAA "Notice of Intent to Removs or Encapsulate Asbestos'form and appropriate fee moo be submitted prior to any asbestos
tamcval work. Asbcstoa removal p-ojects involving demolition must be preformed by a Certified Asbestos Contractor and. all friable or
potentially frahle asbeatcs must be removed before any demolition begins. Refer to ORCAA Regulation. ! A.cttcic :4 for additional
requirements that may apply.
sbestos tlrvey Completed by
ATIERA Certified Inspector
Certification # f1. 2_ _011--}-t`'`
This approved permit must Enclose$2�
be available at thejob site Certification of the Asbestos Survey.must
Processing Fee accompany this form 1-��
0 13 . e NW,Oiynnpia,Washington 98502
58' • r 800-422-5623 + fax 360-491.64D8 RECEIVED•ore epage:www.orcac.org * email. into�c' gicaa.or' �"�� {
Rev.07;I liM2 04
w
MAR 2 4 2005
opr,A f %ink
4101116N
NER BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are eri ccnhdctsrs and that
they will be assuming the responsibility of the General Contractor for the proposed project. \. `
Signature: l l Y
Date: ; ,�--�---- s
;+t',, ma 2 ? ZOoy
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHON i Fps
1> zz 5Z�1 F Cow t LO Zconl t
MAILING ADDRESS: Po e�' -/ .7'�� �,i (EMAIL F) ,-��~^ k,,-..,:-:-.1) ',I1
CONTRACTOR'S LICENSE 1° ` t l' " -
/�'yy /� /' �r Q @� WAIN --
NUMBER: Dt RT�Se... R 6 C 8 O NUMBER
ARCHITECT/ENGINEER:
PHONE ( ) FAx( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: — ❑ Sewer
❑ Addition . ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
VDemolition ❑ 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:
❑ 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 fb
Current Proposed Amount `f " `' . ,,;;,
Main Floor Consistency Review: `
NU _ 1
2 Floor Base fee: ��y .00 '�""�
3`°Floor Additional Section .. i ,;
Mezzanine: Plan Check fee: ' x
Heated Basement State Surcharge fee: r
Unheated Basement Pot Water Revieni;fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport - 11 �,�q_ !`"` --
TOTAL: $ l
Decks
Receipt Number: 1 15 7 14.
Other Cash/Check Number: 2 ,,
ESTIMATED COST(REQUIRED) Date:•Fair market value of all labor and materials foundation to finish 3 G 2
. O
Initials: 7
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
.c". S97 cn\ JEFFERSO NTY 1
`�,� DEPARTMENT OF COMMUNITY DEVELOPMENT � i-' E_,
r'� ' t I - L. ‘ -.
q `- '1 621 Sheridan Street• Port Townsend •Washington 98368 S t :�,,
360/379 4450 • 360/379-4451 Fax I ; MAR 2 2 2005
q`SF�7NG�p www.co.jefferson.wa.us/commdevelopment
Master Permit Application M ;O5 K;'°.1 I ,
Project Description(include separate sheets asinecessary):
ca.—toot, piwu .7 2 B -O Zo (3�- OUvtoaSl
Tax Parcel �_ /� Property / /
Number: 7/> /c/ � ` C/ Size: F�) L ,r (acres/square feet)
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Site Address and/or Directions to P rfy: -"- / t- '�.%'' .eit-i._
t�9 Property Owner(s)of Record: '�c�-�-l' tr.,, 7 r ,
Telephone: 'r'? '.=II' 7 , Fax: --/ . S '1: �'
Mailing Address: '3%3'2- ' 1 Vk,: /6 / "• 0-e.,(ii'-7 !7 .
Applicant/Agent(if different from owner): e% `r 56a
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑ Bu'ding ❑Variance(Minor,Major or Reasonable Economic Use)
Demolition Permit C] Conditional Use[C(a),C(d),or C]**
❑ Single Family iii Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)*"
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat*"
❑ Commercial* CI Binding Site Plan**
❑Change of Use ❑ Long Plat**
❑Address Li Road Approach a Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane n Plat Vacation/Alteration**
Li Allowed"Yes"Use Consistency Analysis [1 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management n Shoreline Management Substantial Development**
El Site Plan Approval Advance Determination(SPAAD)* [I Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
[I Wireless Telecommunication* Ci 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,isle 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 pd right of en to this property shall be requested and shall occur only during regular business
::ure:
�( �/�,� �/ /� •1i/+�1 Date:
r�
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 complian ' the Jefferson.County development code.The Applicant acknowledges that he,she or it holds individual
and non-trans ,? es rbi. t in t and • plyin with the ESA. The Applicant has read this disclaimer anclkigns nd dates it below.
Signature ti S Date: —'e 1
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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