HomeMy WebLinkAboutBLD2005-00188 II?
UILDING PERMIT APPLICAlitN MRAOW00185
Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00188 Received Date: 3/28/2005
SITE ADDRESS: HELM LN
PORT LUDLOW, 98365
OWNER: THOMAS E JOHNSON PHONE: 360-379-6950
JENELL S JOHNSON
62 GARDEN CLUB RD
NORDLAND WA 98358-9610
SUBDIVISION: PORT LUDLOW NO. 1 AREA 1 Block: Lot: 35
PARCEL NUMBER: 990400135 Section: 9 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEW SFR W/ATTACHED GARAGE &
A/G 300 GALLON PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,671
VALUATION 193,903.00 ADD'L: HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: 5N OTHER: 348 SHORELINE:
CONST TYPE: GARAGE: 441 SETBACK:
DECK: 108 BANK HEIGHT:
SEWAGE DISPOSAL: SEW
WATER SYSTEM: LUDLOW
BEDROOMS: BATHROOMS: .
Exist: Exist:
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
I
Type Amount Paid By: Date: Receipt: Approved/Date
Plan Check. $988.10 BAC 03/28/05 71739 APPROVED
State Building Code $4.50 BAC 03/28/05 71739
Potable Water Application $53.00 BAC 03/28/05 71739 MAY 1 9 2005
Permit $1,520.15 BAC 03/28/05 71739
Total: $2,565.75 ff aunty Planning
& : 1ki 'epartment
WI g
tee.. s 6.
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00188 Received Date 03/28/2005
SITE ADDRESS: 95 HELM LN Issue Date 05/19/2005
PORT LUDLOW, 98365
APPLICANT: THOMAS E JOHNSON PHONE: 360-379-6950
JENELL S JOHNSON
62 GARDEN CLUB RD
NORDLAND WA 98358-9610
SUBDIVISION: PORT LUDLOW NO. 1 Block: Lot: 35
PARCEL NUMBER: 990400135 Section: 9 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE &
A/G 300 GALLON PROPANE TANK
CALL IN FOR THE REQUIRE I SPE TIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: D/L 7 / oS^
UFFER: of,
Footing: dZ 7051 J J 006romertly
Foundation: 4< /46.5
Stormwater FINAL Approval:
Underground Plumbing:
Underground Insulation:
Shear Wall : Q(6:psl c
Sheathing:
Framing: O1i q/i�o5 7
Plumbing: /)K S/Z/5,
Propane Tank/ Lines: �,.rge,o &P M fL/uv J 8/76/4S
Insulation: 2/( f/2/O5 4112.45; VA*Lr e/'it *ArewAr/o0, )
Sheetrock:,A'
Septic Sytem Find Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: 3/, 64
HEALTH DEPARTMENT AND PUBLIC WORKS APPR VAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY -SEE REVERSE
SPECIAL CONDITIONS FOR CASE A BLD05-00188 •
1.) 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.
2.) A 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.
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 45%. 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 setback from Helm Lane right-of-way shall be 20 feet. Minimum side and rear
yard setbacks shall be 5 feet.
8.) 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.
9.) 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.
10.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
11.) Per MPR Code Section 3.17, Accessory dwelling units (ADU's) shall not be allowed in the
MPR-SF zone.
12.) The driveway intersection with Helm Ln be graded such that when rainfall runoff slows
down the driveway the water is diverted to Helm Ln roadside ditch. This should be done
to prevent water from flowing out onto the street and into neighboring properties.
13.) A curtain drain interceptor across the entire width of the West end of the lot and drain this
system to the approved drain-line discharge location. A utility easement exists along the
West (uphill) boundary of the lot. The applicant must install the curtain drain outside of
this easement. Before any excavation is accompolished near this easement, location of
utilities with the easemnt is strongly recommended.
14.) Houses in known drainage problem areas may be required to install a Curtain Drain
system usually this will be located up-slope from the proposed home. This system will
usually be required to have a separate drain-line to the approved discharge location. The
drainage plan must show the location of the curtain drain and a cross section indicating
the depth and back fill material.
15.) The applicant must have all easement documents related to drainage finalized and
recorded prior to PLDD drainage plan approval for Jefferson County building permit and
Ludlow Maintenance Commission Architectural Control Committee approval.
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16.) Approval drain-line discharge locations are road ditch and drainage easement with a
defined ditch either natural or man made.
17.) No dry wells, dispersion ditches, infiltration swale, holding and slow release systems etc.
will be approved unless designed by a Licensed Civil Engineer or Licensed On Site
Designer. Any plans of this type must include the designer's current State of Washington
stamp, signature and date.
18.) The Drainage Plan should be drawn at a scale of 1-inch equal 10-ft and must show:
1. Outline of the lot with dimensions of each side.
2. Contours at 2-ft intervals, (The Drainage District can supply the applicant with this
information)
3. Outline of the footprint for the proposed house showing setback dimensions from
property lines.
4. Locations, size, type (perforated or tight), and route that the drain lines follow to drain
line discharge location.
5. Locations of roof drain downsprouts.
19.) Houses must have as a minimum: perforated footing drains and separate tightline for roof
drains. Details of these drains must be included with the drainage plan.
20.) Driveways that slope downward from the road must have a method to collect rainfall wter
into the roadside ditch at the driveway entrance. A detail drawing of this grading must be
included with the drainage plan.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
14
STORM%VATE}� PLAN
W °� JEFFERSON COUNTY ti�gy r 2005
+ f� ►• DEPARTMENT OF COMMUNITY DEVELOPMENT
4 , , 621 Sheridan Street • Port Townsend • Washington 983:: bFhT JEFFERSON COON
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STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA#
c .3- PROJECT/APPLICANT NAME: sT74 or-tAS 7"6NNSv N/
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 --- 1-6/ 3S / /I'( LAVE 1 Po :r /- tDi o '
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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5. Describe the existing site hydrology(i.e., drainage; behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable, and indicate acreage of each.
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6. Describe any excess levels of noise generated by the proposed use or activity:
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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.
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8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads, and sensitive/critical areas
(streams,wetlands, lakes,steep slopes, etc.).
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
9. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed(i.e., per BMP T5.30
in the Manual) or, if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for"large"projects or projects that involve the potential for dispersion of contaminants.]
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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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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 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/' restorationti/ of the site.'- y /�/
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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.
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.
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stormwater site plan template.doc—rev.10/12/2003 _
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.
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes. .
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7. Protect Drain Inlets.
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stormwater site plan lemplate.doc—rev.10/12/2003 - 8
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).
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11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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stormwater site plan template.doc—rev.10/12/2003 - 1 9
b. Description of special requirements for working in or near environmentally sensitive areas.
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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).
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5. Construction Phasing. (N7-
a. Construction sequence � I I_�fA/! MPS -� SST 2/u M Aknt.�
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b. Construction phasing(if proposed)
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
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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.
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable.
a. Sediment Ponds/Traps. AJA-
b. Diversions.
c. Waterways. � .... _..._. _.._ _.___....___,: ... :.
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d. Runoff/Stormwater Detention Calculations L
stormwater site plan template.doc—rev.10/12/2003 10
Stormwater Site Plan Changes _
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes, and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal •
If the project included construction of conveyance systems, treatment facilities, flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs), the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property.
/0/-0- 11 f t ia-1)//) Io rt-- — I—C(LANDOWNER OR AUTHORI REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stormwater site plan template.doc—rev.10/12/2003 12
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N0Q J EFF COUNTY
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DEPARTMENTERSON OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend•Washington 98368 ? - �
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el360/379-4450.360/379-4451 Fax ,!tg f
http://www.cojefferson.wa.us/commdevelopment/
Stormwater Calculation Worksheet •
MLA# C '� I SD PROJECT/APPLICANT NAME: 'TNGIV 4S b i4A/So aV
DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first
to classify the proposal as"small,"'medium,"or large." The size determines whether a Stormwater Site Plan is required in conjunction
with a stand-alone stormwater management permit application, building permit application, or other land use approval application that
involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan,if required.
PARCEL SIZE(I.E.,SITE)
Size of parcel •7-86 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet I t/H 60 sq/ft
Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and
non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling,
excavation,and compaction associated with stabilization of structures and road construction.
Native vegetation is vegetation comprised on plant species,other than noxious weeds,that are indigenous to the coastal region of the
Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as
Douglas fir,western hemlock,western red cedar,alder,big-leaf maple,and vine maple;shrubs such as willow,elderberry,salmonberry,
and salal;herbaceous plants such as sword fern,foam flower,and fireweed.
LAND DISTURBING AC1IVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL
Calculate the total area to be cleared,graded,filled, Answer the following two questions related to
excavated,and/or compacted for proposed development conversion of native vegetation:
project. Include in this calculation the area to be cleared for:
Does the project convert'acres or more of
Construction site for structures 1` P sgfft native vegetation to lawn or landscaped areas?
Drainfield,septic tank,etc. / e G we .) sq/ft Circle: Yes
Well,utilities,etc. /i/4- ( PH 81-/C ) sq/ft Does the project convert 234 acres or more of
Driveway,parking,etc. Z,000 native vegetation to pasture?
Circle: Yes ��
Lawn,landscaping,etc. ,846 to sq/ft
Other compacted surface,etc. AM" sq/ft Indicate Total Volumes of Proposed: -
Total Land Disturbance /27 '16 0 sq/ft Cut Fill 50 (cu/yd)
[over]
stormwater calc worksheet—REV.10/1/2003 1
•
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions
prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow
from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof
tops, walkways, patios, driveways, parking lots or storage areas,concrete or asphalt paving, gravel roads, packed earthen materials,
and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.
STORMWATER CALULATIONS—IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) f 2 00 sgift Structures(all roof area) sclift
Sidewalks 4 0 sq/ft Sidewalks sciftt
Patios sq/ft Patios sqfft
Solid Decks 10,-S0 sq/ft Solid Decks scit
(without infiltration below) (without infiltration below)
Driveway 11 6 sq/ft Driveway sq/ft
Other _ sq/ft Other
Total New �! 7 !� sq/ft Total Existing �'6' / sq/ft
TOTAL NEW+TOTAL EXISTING* 7/0 sq/ft `This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v.REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: ► %
Does the site have 35%or more of existina impervious surface? Circle: Yes
FURTHER INSTRUCTIONS: If the answer is yes, the prop_usal is considered redevelopment and the attached Figure 2 should be
used to determine the applicable Minimum Requirements.: If the answer is no,the proposal is considered new development and the
attached Figure 1 should be used. At this juncture,the applicant should refer to the applicable Flow Chad to determine the Minimum
Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements.
For proponents of "smalr projects who must comply only with Minimum Requirement *2—Construction Stormwater Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and
prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction
Stormwater Pollution Prevention (SWPP)Best Management Practices(BMPs)Packet. Proponents of"medium"projects—those
that must meet only Minimum Requirements #1 through #5—,and.for 'large" projects—those that must meet all 10 Minimum
Requirements—are required to submit a Stormwater Site Plan. DCD has prepared,a submittal template of a Stormwater Site Plan,
principally for rural residential projects. Complete the template in the Stonnwater Site Plan Instructions and Submittal Template or
prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual.
AP.PLI( ANT SIGNATURE
By signing the Stormwater Calculation Worksheet, I as_the_applicant/owneratte if at 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. {
o ; _
/ i�rnacvi. tl y _ 3 "7 L C��
(LANDOWNER ORAUTHO ED REYRESBVTA7NE SIGNATURE)
stormwater calk worksheet—REV_10/1/2003 2
ira co JEFFERS.COUNTY i - ----
' DEPARTMENT OF COMMUNITY DEVELOPMENT !m 1
621 Sheridan Street• Port Townsend •Washington 98368 i
4• 360/379-4450 • 360/379-4451 Fax l 0
,q ��0 www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: 0 J- 1
Project Description(include separate sheets as necessary):
C (//_LE f,./4All 1 - a
,'i/� f L ( iv,/4 r-rAcl/ 64d-4O r
Tax Parcel
Number: qq®�d0/3S Property
Size: .Z2,r6 4c71Z, Z(acres/square feet)
Site Address and/or Directions to (��� q8 3 65
Property: 3S /i�'�.nr t.��/� � PoRrl-�c��.aw WA
Property Owner(s)of Record: 771O 1AS . ', JoHU SoN
Telephone: 3600-379-69So het-tfar360 - 77'I-lz7t email: T,y..:nil oisan61ICli104-com-t
Mailing Address: 6Z 6-A2DEM cups Rails , Arm64...aki6 w4 1.9 3 58
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
at kind of Permit?(Check each box that applies)
Building 0 Variance(Minor,Major or Reasonable Economic Use)
❑pemolition Permit 0 Conditional Use[C(a),C(d),or CI**
t' Ingle FariIy_____ ❑ Discretionary"Dv or Unnamed Use Classification
Garage(Attached Detached 0 Special Use(Essential Public Facilities)"
❑ Manufactured Home 0 Boundary Line Adjustment
❑ Modular ❑ Short Plat"
0 Commercial* 0 Binding Site Plan"
❑ Change of Use 0 Long Plat"
0 Address 0 Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
0 Mowed"Yes*Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions"
0 Stormwater Management 0 Shoreline Management Substantial Development"
O Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 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 7liG"IAS ,GNJV So A,1 to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE 71144.-- 90A41"341 - _ Date: I3 - 1r OS
By signing this application form,the owner/agent attests that the kifu,unation 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 attorneys 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: /erM /Q" w _ Date: 3• —7) ''bs
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
and non-transfera�b sponsibia for adhering to and complying Applicant acknowledges this
disclaimers that he,she sr andit holdsa individual
sibl
tY nng p ying with the ESA. The Applicant has read this and signs dates it below.
Signature: / Date:
G:\PennitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT
1
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 I
they will be assuming the responsibility of the General Contractor for the proposed project. 1 —.
Signature: ��Lanvr.,� rb.44-1-1417✓ Date: — OS J $ 2005I
f
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: 1 FAX: `
GwNTit eka-4' ( ) L ( )
54
MAILING ADDRESS: _S ,r Peen,jtZ OL AJC EMAIL:
'IG
CONTRACTORS LICENSE WAINS
NUMBER: K./A- NUMBER
ARCHITECT/ENGINEER: iv-4 PHONE ( ) FAX:( )
MAILING ADDRESS: EMA
P r9ject Type: F me Type: Bathrooms: Shoreline: Type of Sewage Disposal:
V New V Wood Existing: A/.4 Vrgewer
❑ Addition 0 Steel Proposed: 1- Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: 1 Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well ❑ Two Party
Type of Heat: Proposed: 3 lePublic
Fe/4 G .►& Ai R Total: 3 Name of System:
(WWEkr PcuHp) al-YMP/c Wil 7riVsisr.dep
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
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
O Underground Tank VAbove ground Tank Size of Propane Tank: 3CP0 14-04
❑ Heat Stove ❑ Cook Stove 0 Woodstove fireplace Insert ❑ Hot Water Tank 0 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 a @} e" .1**,--..,,,,),,*qN,.4 'a,�+ 4'4gs` - 4w J� •
--•"-'
Current Proposed '� s 1` `, j` i : ti ••mot fFt.- AeL rIi �h j V. r' v� •wx'sy
Main Floor t 6 7 I �,. - :,j • r t w%� `' r:A . c.�c-l.G
2' Floor 4�,, , `: ", rr ' ; �4 "4 rat, .; 4 4 r4
ten`'+::t'}=X'":: t ° . �� :.,Z•��..`<i.-�4:'' '`t3 2' ' �; � � '� a t'�"^''
3f0 Floor ', �. -Y a ''`, .,, +�
'` f..It �• '�rt� tfe'!`y iE yx I• g4
' `-1.` ' 1- k�4y1�k X;., 1�„ray ..._ 3S1iiFvnk I {s. kS ve' �c��j
Mezzanine: f. `` 1k7r "` "& ° : 4^e^+ry `'ice a g^s 'iiS ' b', �L
^-t 1 1 }4�.�. 1y� i� 4'�: its '
' ,r.s t i tita:•'* Litt. .rx. �1n a ci,r t xt,
• A r 4; ..t i 1 �1 t.• 2>Intan sn. Cam(",
Heated Basement I ,'sl �` `, ` , t-"` " R - r ` >+ 4
Unheated Basement a 4 ri 0...F4'N O f•Gl%
>. q 1 R a � ^. s� 7 ,'7 4
Other Unheated '�`ti , - -;-• 40, �.,� �s ,� �y, y ,,
r ti t 4'A , a ,r tri''' - i..4 �i 5 t ' � 1 a 1•tx
Cyi{, e.P,.M ' 'tzt' I e 6 j.. , �,,,x:-zrr` A,.' r ' C .?�a�.t S g c
/��({I/,� .iY-+ c. - � £ yrt,%' 0�'. 9�` '^f.t� �'``7� � v-a s ^ri.�'T>�� nc. � ,H,.
'-
Garage/Carport / 1 / a '. 4 'S� y(-` b +� Y wM `.ta F51. }
Decks
v 4 _+'-'E n lyK, nk4> ,r -+4.s- 'S 4
,. 4 ; ,_ 1 t e ,ri • h -- y J-i'N k'.14 ter y . '-';'r �4"'-' 11 i j
'AHt l sD.J L(S r firi'!'e i , , $ i'8r i'yL T . z F
v 3 8 .y r r.i5 L• r Asi i ra'�'.y, ii • w t ¢... .r3 -..."'' 2
ESTIMATED COST(REQUIRED) hf' }} • yykkc� p,,C -, `` ''' A
•Farr market value of all labor and materials T Y , F">: y' a, " v , ti ; „ry, +„ . `-6''
• a ,; �n c c S s �z,�., • _
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A SURVEY OF LOT 3 5 IN THE PLAT OF PORT LUDLOW NO. 1, AREA 1, SITUATED IN THE S - W. 114
OF SECTION 9, TOWNSHIP 28 NORTH, RANGE 1 EAST, W.M., JEFFERSON COUNTY, WASHINGTON
7
W
E
S
PORT LUDLOW NO.7, AREA 1
VOLUME 5, PLATS, P.26
SURVEYOR'S NOTES:
BASIS OF BEARING:
a
N
N 16'48'09" E, BETWEEN THE ENCASED STREET
,m,
MONUMENT AT THL INTERSECTION OF "WALKER
WAY' & "HELM LANE" AND THE ENCASED CENTER
0) ome
OF CUL-D-SAC MONUMENT AT THE NORTHERLY
"HELM
Rrn--�m
TERMINUS OF CENTER LINE OF LANE"
SITUATED IN AND COINCIDING WITH THE PLAT
a.��
o:n�
OF PORT LUDLOW NO. 1, AREA 1, PER VOL. 5,
>am"
PLATS, PG. 26. JEFFERSON COUNTY. WA.
W
EQUIPMENT USED:
THIS SURVEY WAS PERFORMED USING
A SOKKIA SET 3110 ELECTRONIC TOTAL
STATION THEODOLITE/E.D.M. DURING
z
�
CLOSED RANDOM TRAVERSES FROM AND
z
BETWEEN EXISTING PLAT MONUMENTS.
U
w
CONTROL ACCURACY:
THIS SURVEY MEETS OR EXCEEDS STATE MINIMUM
MONa
ACCURACY REQUIREMENTS OF 1:5,000 FOR
a
"(b) CITY -RESIDENTIAL AND SUBDIVISION LOTS"
PER W.A.C. 332-130-090.
� i
o
U
C
Y
2-15-05
SURVEYOR'S CERTIFICATE
THIS MAP CORRECTLY REPRESENTS A SURVEY MADE BY ME OR
UNDER MY DIRECTION IN CONFORMANCE WITH THE REQUIREMENTS
OF THE SURVEY RECORDING ACT AT THE REQUEST OF....
TOM JOHNSON
IN FEBRUARY 2005
FINIS H. BREWER. CERTIFICATE N0. 36791
AUDITOR'S FILE NO.
AUDITOR'S CERTIFICATE
FILED FOR RECORD THIS�p,D'A tO,F .L 2�ATiJ�.M.
IN BOOK � OF , u1tybT S AT PAGE AT THE REQUEST OF
AUDITORFINIS H. BREWER.
COUNTY Ito jo v
JOB NO.: 05002
FILE: 05002_JOHNSON
FIELD BK: 17, PG. 5
SURVEYED BY: WCR/MJL
DRAWN BY: RWR
CHK'D BY: FHB
THIS SURVEY WAS PERFORMED IN
JEFFERSON COUNTY, WASHINGTON FOR:
TOM JOHNSON
O 30 60 90
SCALE: 1'= 30' (ORIGINAL)
LINE TABLE
LINE
LENGTH
BEARING
L7
10.00
N24'42 34 E
CURVE
TABLE
CURVE
I LENGTH
I RADIUS
cil
24.341
45.W
REFERENCE SURVEYS:
VOL.
5,
PLATS. P.26, IT. LF"LOW
10.1, AREA 1)
BK.
26,
SURVEYS,
P.148, F.
BREWER
BK.
14,
SURVEYS,
P.113, L.
G. HALL
BK.
20,
SURVEYS,
P.88, A
"'DOD
BK.
22,
SURVEYS,
P.40, A
DOD
BK.
14,
SURVEYS,
P.51, A.
WOOD
PROPERTY DESCRIPTION
LOT 35, PLAT OF PORT LUDLOW NO. 1, AREA 1,
SITUATED IN S.W. 1/4, SEC. 9, T.28N., R.1E., W.M.,
JEFFERSON COUNTY, WASHINGTON.
LEGEND
O FOUND MONUMENT AS DESCRIBED
FOUND CASED CONCRETE MONUMENT
VISITED DEC. 2003
PROPERTY LINE SURVEYED
INDEX GRAPH
S.9, T28N. R1E, W.M.
JEFFERSON COUNTY, WA.
1—
L1J
W
cn
AMERICAN LAND SCIENCE
PROFESSIONAL LAND SURVEYING
POS 547
6396 STATE ROUTE 19
CHIMACUM, WA. 98325
TELE: (360) 732-031 1