HomeMy WebLinkAboutBLD2005-00267 tILDING PERMIT APPLICAT O ML Review T Ty 255
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00267 Received Date: 4/27/2005
SITE ADDRESS: 1229 EAST QUILCENE RD
QUILCENE, 98376
OWNER: DAVIS R STEELQUIST PHONE: (206) 351-4254
PO BOX 218
QUILCENE WA 98376 QUILCREST VIEW TRACTS
SUBDIVISION: Block: Lot: 2
PARCEL NUMBER: 701185002 Section: 18 Township: 27 N Range: 01 W
CONTRACTOR: PRATT CONSTRUCTION COMPANY PHONE: 360-452-3360
112 J SHEA WAY
PORT ANGELES WA 98362-8169
Contractor's License PRATTCC210JL Expires 3/25/2007
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEW SFR
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,881
VALUATION 250,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: 336 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: • Exist:
Prop: 1 Prop: 2
Total: 1 Total: 2
Routing Date: , I/
agib6%.)-_,
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,833.75 BAC 04/27/05 71899 APPROVE .
Plan Check $1,191.94 BAC 04/27/05 71899
State Building Code $4.50 BAC 04/27/05 71899 JUN 1 3 200
Potable Water Application $53.00 BAC 04/27/05 71899
Jefferson County Planning
Total: $3,083.19 RctiLt B Department
COX- SCM,
0 ' e
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: . BLD05-00267 Received Date 04/27/2005
SITE ADDRESS: 1229 EAST QUILCENE RD JL4j C4sc4rck Issue Date 06/13/2005
QUILCENE, 98376
APPLICANT: DAVIS R STEELQUIST PHONE: (206) 351-4254
PO BOX 218
QUILCENE WA 98376
SUBDIVISION: QUILCREST VIEW TRACTS Block: Lot: 2+
PARCEL NUMBER: 701185002 Section: 18 Township: 27 N Range: 01 W
CONTRACTOR: PRATT CONSTRUCTION COMPANY PHONE: 360-452-3360
112JSHEAWAY
PORT ANGELES WA 98362-8169
360-452-3996
Contractor's License: PRATTCC210JL Expires: 3/25/2007
PROJECT DESCRIPTION: NEW SFR
CALL IN FOR THE QUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS:
UFFER:
Footing: 9-go--oi
Foundati n:
Stormwater FINAL Approvi Underground Plumbing: BPPD BY 1-. (O// D5
Underground Insulation:
Shear Wall : p t:- q-'(f5 a(,.,
Sheathing:
Framing:1 .rtoc/c.:S. 10'6-9S rte., kit:ix-047i7aGTS
Plumbing: d YL_. 4-03--o(Q
Propane Tank/ Lines: 44`1- A- '�j-p 0Insulation: Aif� A .. 0 511#a, dK 0004#(ia us tCa►uucJ
Sheetrock:
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Z.•••. Final Approval: • God ��
darit Approval:
HEALTH DEPARTMENT AND PUBLIC W RK 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
•
SPECIAL CONDITIONS FOR CAPE t BLD05-00267
1.) A vegetative buffer of 25-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
2.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated.
Should buffer disturbance occur during construction, the Unified Development Code
(UDC)Administrator shall require replanting with native vegetation. No alterations shall be
made to the Landslide Hazard Area or its associated buffer without prior authorization by
the UDC Administrator.
3.) A Geotechnical Report was submitted in conjunction with this application. The report
addressed the stability of the geologic hazard area. A setback of 25-feet shall be
measured perpendicularly from the top or toe of the geologic hazard to the proposed
single family residence.
4.) Prior to and during approved construction activities, the perimeter of the landslide hazard
area buffer shall be marked with a temporary sign. The sign shall be placed in such a
manner that it can be directly observed from the construction area. The sign shall contain
the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter
Existing Vegetation."
5.) All construction activities shall not encroach upon the buffer. This includes the storage or
preparation of materials.
6.) The applicant shall permanently separate the boundary of the Landslide Hazard Area
Buffer from the remainder of the subject property through installing logs, trees, a hedge
row, or any other prominent physical marking approved by the UDC Administrator.
7.) A setback of 50-feet, measured perpendicularly from the wetland edge, shall be
permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the
wetland or its buffer is allowed.
8.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or
every one hundred (100) feet, whichever is less. Signs shall contain the following
statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation."
9.) A permanent physical separation along the upland boundary of the wetland buffer area
shall b?installed and permanently maintained. Such separation can include installing
logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC
Administrator.
10.) The identified Fish and Wildlife Habitat Area (Type 4 Stream), shall maintain a vegetative
buffer setback of 100 feet. The setback shall be measured horizontally from the Ordinary
High Water Mark (OHWM) to the single family residence.
11.) An additional setback of five (5) feet is required from the edge of the buffer area to the
proposed single family residence.
12.) A permanent physical separation along the boundary of the buffer area shall be installed
and permanently maintained. Such separation can include installing logs, trees, a
hedgerow, or any other prominent physical marking approved by the UDC Administrator.
13.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or
every one hundred (100) feet, whichever is less. Signs shall be in place prior to and
during construction activities. The signs shall contain the following statement: "Buffer- Do
Not Remove or Alter Existing Vegetation."
14.) 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.
15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
16.) Not more than two (2) unlicen•or inoperable vehicles shall be stored on• 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). •
17.) Maximum impervious surface coverage is 25% of the parcel. Impervious surface is
defined as a surface area that creates a barrier to the entry of water into the soil in
comparison with natural conditions prior to development, or that causes water to run off
the surface in greater quantities or at an increased rate of flow in comparison with the flow
prior to development. Common impervious surfaces may include roofs, driveways, patios,
packed earth, and oiled surfaces.
18.) The building height is not to exceed 35 feet.
19.) Mlnimum front setback from the edge of the easement adjacent to and within this parcel is
20 ft. Minimum side and rear setbacks are 5 ft. Environmentally Sensitive Areas further
impact setbacks.
20.) A minimum of two (2) on-site parking spaces are required for the single family residence.
•
•
I:\F_BLD_Permit_Buildng.rpt 10/29/19
' � c��� JEFFERSON COUNTY -
DEPARTMENT OF COMMUNITY DEVELOPMENT 1,t 4i4 ,
i
621 Sheridan Street• Port Townsend •Washington 98368E ,
q 360/379-4450 • 360/379-4451 Fax g APR 2005 C
G` http://www.co.jefferson.wa.us/commdevelopment/ i t
Stormwater Calculation Worksheet
MLA# 0 C3-' a n PROJECT/APPLICANT NAME: ut.N G. d[C AR`
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.E2 SITE)
Size of parcel y2 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 'Z 'a 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 ACTIVITY,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 3/,acres or more of
Construction site for structures \\�'V 'lift native vegetation to lawn or landscaped areas?
Drainfield,septic tank,etc(tu/.4i s'IJCs. ) I o sq/ft Circle: A No
Well,utilities,etc. JJ# 'i? sq/ft Does the project convert 21 acres or more of
native vegetation to pasture?
Driveway,parking,etc. ;t
Circle: Yes No
Lawn,landscaping,etc. 52b) sq/ft
Other compacted surface,etc. sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance it,ct sq/ft A PP ] 6D Fill (cutyd)
S`RP WATER VLAT4
[over]
JUN -
7 2005
stormwater ode worksheet—REV.10/12003 JEFFE N COUN 1
I)EPT.OF COM NI IN r •vi; ,,
SIGMA rr iN
•
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditiori?3
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
EW EXISTING
Structures(all roof area) 04 L 1(. • sq/ft Structures(all roof area) " 3 sq/ft
Sidewalks 'b—' sq/ft Sidewalks O sq/ft
Patios 4:3—, sq/ft Patios O sq/ft
Solid Decks "e—' sq/ft Solid Decks b sq/ft
(without infiltration below) (without infiltration below)
Driveway sq/ft Driveway Zbbb sq/ft
Other sq/ft Other sq/ft
Total New 241 v sq/ft Total Existing 31(5—S sq/ft
TOTAL NEW+TOTAL EXISTING* CST-5 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: t• %
Does the site have 35%or more of existing impervious surface? Circle: Yes 6 No)
FURTHER INSTRUCTIONS: If the answer is yes, the proposal 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 Chart 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 "small" 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 Stormwater Site Plan Instructions and Submittal Template or
prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual.
AP i CANT—SIGNATURE TUR€------—I
By signing the Stormwater Calculation Worksheet, I as Mt) 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. APR 2 7 23: j
C.
tk.,kZ b T
(LANDO OR AUTH REPRES AT1VE SIGNATURE) [ _ (DATE)
1
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stormwater talc worksheet—REV.10✓1/2003 2
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.~ sOzv � JEFFER N TY � �--._`— _, �,SO COON; DEPARTMENT OF COMMUNITY DEVELOPMENT -
APR 2 7 2005
621 Sheridan Street • Port Townsend •Washington 983681 .- -
360/379-4450 • 360/379-4451 Fax
to ` http://www.co.jefferson.wa.us/commdevelopment/ -- —�
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# C.,.Y,at-5 _ PROJECT/APPLICANT NAME: V t. ' 1.C :1"-t,l!,.
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.
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2. Describe the existing topography. Indicate contours ion the site map.
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.
0
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 t
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4 6. Describe any excess levels of noise generated by the proposed use or activity:
stormwater site plan template—rev.10/1/2003 5
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
(str ams,wetlands,lakes,steee 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.
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 Jhe site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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
norm ly for large"projects or projects that involve the potential for dispersion of contaminants.]
ra.-
11. Des rjbe the performance goals and standards applicable to the project.
l/�-
12. Describe the flow control system. ;: T +
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stormwater site plan template—rev.1 N7/2003 6
13. Describe the water quality system.
14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
SIP
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
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17. Describe the proposed surfacing material.
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18. Describe methods for restoration of the site.
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. }
{ t' 2 7- 2`O65 i
4.
stormwater site plan template—rev.10/1/2003
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.
2. Establish Construction Access.
N.
3. Control Flow Rates.
4. InstallSediment Controls.
,014,
5. Stabilize Soils.
6. Protect Slopes.
7. Protect Drain Inlets. (
►.2 be 1 APR 2 7 2005
stormwater site plan template—rev.10/12003 8
' 12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
9. Control Pollutants.
fV� _
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
12. Manage the Project.
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
N
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—rev.10V1/2003 "
b. Description of special requirements for working in or near environmentally sensitive areas.
ti
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-sire
soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure). 1
113 J 4 ,.�J r-�_ L..,L. P_ Ir `.W a ,�sc]rr'-q .�ht.?i�5
5. Construction Phasing.
a. Construction sequence
A_9 4
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a pro osed construction schedule.
II. Wet Season Construction Activities.
a. , Proposed wet season construction activities.
4
b. Proposed wet season construction activities for environmentally sensitive areas.
A° *r
7. Financial/Ownership Responsibilities. �Ie
a. !Jag::prope caner responsibJ a initiation of bonds and/or other financial securities.
t5 ��
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
Vipc-
8. Engineering Calculations. Provide Design Calculations on a separate sheet for th4 following, if applicable.
a. Sediment Ponds/Traps. ti*,
b. Diversions. tip . �� ��� 7' 111
c. Waterways. ti4,... I ;�P 7 20n5
4
d. Runoff/Stormwater Detention Calculations ,...J 1 tr.' ,
storrnwater 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 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.
• IP1t "7-.1
( WNER OR A. '•RIZED REPRESENTATIVE SIGNATURE) O
A(
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
I APR 2 7 2005
stormwater site pan template—rev.10/1/2003 12
r,k oN c, JEFFERSON�UNTY 7�AA D Z o 3c
,a DEPARTMENT OF COMMUNITY DEVELOPMENT
`4 I 621 Sheridan Street • Port Tdwnsend •Washington 98368
360/379-4450 • 360/379-4451 Fax ; • -
.q O www.co.jefferson.wa.us/com(ndevelopment 1,
SNS
.. APR 2 7 2005
Master Permit Application ' I MLA: o3—at3�
Project Description(include separate sheets as necessary): ""
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Tax Parcel ` ra
Number: lot t�sc�z Property S► (1 Z kai. (acres/square feet)
Site Address and/or Directions to Property: 1.22S, t€!r Q,,,,k ,a �)
Property Owner(s)of Record: DINVLS .S"{egn.s th4 b
Telephone: Qua 35 t - 7 4 Fax: 4 email �{R 3")LQ
Mailing Address: O•-0.4, Z(,8 Qv,ke_ajv �",Qcs-jf„ Cm$kcs?eits>.e.A_NAA,
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
pit/Building ❑Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
'Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
❑ Manufactured Home 0 Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑ Change of Use 0 Long Plat**
El Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
0 Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development'*
❑ 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 `}.-2-... Date: (42t31-
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 inspec' s.Access and right of entry to this property shall be requested and shall occur only during regular business
hours. ---
Signature: X t �t_ _ 4�2
Date: ll
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 - •!th the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non- ferable res nsibili, ` ring to and complying with the ESA. The Applicant has read this di aime and sig and dates it below.
Signature:�� �� Date: Nt2 4,O>
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:
•
GEN=RAI CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
-TT, M.a:el- L` a&95 vLhc ( o)452.-33`a 360 '1$Z 3996
MAILING ADDRESS: •
'//2 ,TS4/44 Wirt Po/IT 4 ' 'S 0342 EMAIL:-r -re 154.-yRelli. .Ltl,N,..
CONTRACTOR'S LICENSE J 2/4TTCc 02/0 JL WAINS
NUMBER: '3 NUMBER
ARCHITECTOEN6tNEER: (-r4 _../.424404.��%kJ PHONE (34o) SZ7.01t4kFAx:(3t ) 527 -o(4rZ
MAILING ADDRESS: (4.01 5 k X'LSt-I,cAt&+e In Actik EMAIL
1t A1Coy" 2..-. ( ""l eiv O (3430) 2 -2 V -( c)Iii - 2.6.11f q 1 .;�;— -71 r
Project Type: Frame Type: Bathrooms: Shoreline: Type of - age Disposal:
K New IeWood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: 2 Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: kndividual System
❑ Repair ❑ Masonry SEP Permit#
Ill Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
Total: 1 Name of System:
If this is a Commercial Protect you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
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 0 Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured I Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also Omit a site plan showing all of thetbuildings,all property
lines,tank location and size,distances from the propane tank to all roperty lines,buildings and septic l ystem components,
including the reserve area. _ E
Square Footage For Office Use Onl . s
Current Proposed APR
Main Flooro
ibk Cons' t ,Review . -, % "`, , `
il 2 Floor Base e: ;, '-n-r.,,,:-. A
iLt� i `' 6-.
)
ttional Section:40
3`tl Floor x .
Mezzanine: Plan Check fee:D 61 t ,"1 �(� 1 nt`'1"1
Heated Basement o State Surcharge fee: ' p
Unheated Basement O Pot Water Review fee: a/
i ,
ADU
Other Unheated 911/Rd Approach fee:
oe`�1 :
Garage/CarportTOTAL: $ ` { f � ,.
Decks (DitbLL$1•.3C;CCObser4-4 NC) 53 te 1 qReceipt Number:
Other Cash/Check Number: t' ¢f c
r �ti ate= �ljj,_
ESTIMATED COST(REQUIRED) I 513
1^ ate,: �`�1 . .� I
•Fair marke -aHiabo aterialsioundabon to k usli )
Initials:
a tDc:_C)_________e__9 ..,z,r.4= ''''i -
G:\Permi S\IRD FORMS\Master Permit Application 7-8-04.doc