HomeMy WebLinkAboutBLD2005-00269 *UILDING PERMIT APPLICAN MLA05 00259
Review
Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00269 Received Date: 4/29/2005
SITE ADDRESS: 113 MATS VIEW TERRACE RD
PORT LUDLOW, 98365
OWNER: MICHAEL L FULLER PHONE: 253-797-6845
LAUREEN J FULLER
113 MATS VIEW TERRACE
PORT LUDLOW WA 98365 MATS VIEW TERRACE
SUBDIVISION: Block: Lot: 4
PARCEL NUMBER: 970900004 Section: 5 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: HAROLD MOE CONSTRUCTION PHONE: (360) 437-7994
CHERYL HILBERT
104 MATS VIEW TERRACE
PROJECT DESCRIPTIOI NEW SFR W/ATTACHED GARAGE
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,843Mu'
VALUATION 22,500.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: HTP
OCCUPANCY: R-3 UNHEATED: 1,363 hwc""'A# OF STORIES:
OCCUPANCY: OTHER: 316 -L1/44
CONST TYPE: 5-1HR GARAGE: 480 in�J SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CMY
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 2 Prop: 2
Total: 2 Total: 2
Routing Date: T—/ o,s--- fa;
Type Amount Paid By: Date: Receipt: ����v� V
Permit $1,693.75 BAC 04/29/05 72935 V
Plan Check $1,100.94 BAC 04/29/05 72935 AUG -- 1 2005
State Building Code $4.50 BAC 04/29/05 72935
Potable Water Application $53.00 BAC 04/29/05 72935 gfferson County Planning
Total: $2,852.19 &B : Department
i •
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00269 Received Date 04/29/2005
SITE ADDRESS: 113 MATS VIEW TERRACE RD Issue Date 08/1/2005
PORT LUDLOW, 98365
APPLICANT: MICHAEL L FULLER PHONE: 253-797-6845
LAUREEN J FULLER
113 MATS VIEW TERRACE
PORT LUDLOW WA 98365
SUBDIVISION: MATS VIEW TERRACE Block: Lot: 4
PARCEL NUMBER: 970900004 Section: 5 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE
CALL IN FOR THE REQUIRED IN PECTIONS THAT APPLY T9 Y UR PROJECT. Foertruec 4 S,No 14 E
SETBACKS: j�/� .p£4 1t CA) $ITS %/4' FortPoRctl ode ifit r
UFFER: �Ajo
Footing: TE2/1NOfbie 49/46, gccAminut �ajJ- re-pop•u dt ► 10.7/OP
Foundation: UK q(t'h5 r iEritiuiut zJ�� Ok 01047
Stormwater FINAL Approval: t2k GM2d,yy/J�
Underground Plumbing: ))/a, v
Underground Insulation: WA,
Shear Wall : eEMB.En wS PAGKA44
Sheathing: NA
Framing: (rrt Am, 3 t� !, • rizilAftwrok #fl vA1.*1-c 3/zG/0(�
Plumbing:
Propane Tank/ Lines:
Insulation: gawk* pV�2 VAu ra P 5.5 PIok.04, b4i D,
Sheetrock:
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: •
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY -SEE REVERSE
41,
SPECIAL CONDITIONS FOR CAt BLD05-00269
1.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
2.) The development will be serviced by public water and a well will not be utilized. If a well is
required for potable water the applicant shall meet all of the Aquifer Recharge and SIPZ
conditions.
3.) 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.
4.) A Medium Stormwater Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
5.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
6.) 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).
7.) Pre-existing legal lots of record less than one acre in size in Rural Residential districts are
subject to the stormwater requirements in UDC Section 6.7 and must meet the"Area of
Impervious Surface Coverage"to the maximum extent practicable as determined by the
Administrator." Lot coverage is defined as amount of impervious surface, which includes
rooftops, driveways, concrete, etc.
8.) The building height is not to exceed 35 feet.
9.) Setback from Mats View Terrace Rd. right-of-way is no less than 20 ft. and rear setback is
no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more
restrictive setback shall apply.
10.) 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.
11.) 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.
12.) A minimum of two (2) on-site parking spaces is required for the single-family residence.
13.) Deferred submittal for retaining wall allowed.
Wall must be engineered for site.
Submittal to be received and approved prior to stem wall inspection.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
(Arriiiks, 14)
JEFFERSON COUNTY
APR 2 9 2005
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
http://www.co.jefferson.wa.us/commdevelopment/ ---
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
•
MLA# % �` r C PROJECT/APPLICANT NAME:
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. - , t
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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.
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:
5 stormwater site plan template-rev.10/1/2003
1
7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, -
st rp 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 perform(a4nce��(/J/foals and standards applicable to the project.
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12. Describe the flow control system.
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stormwater site plan template-rev.10/1/2003 6
13. Describe the water quality system.
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14. Describe the convey ;e systems analysisy 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 ompaction 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 me cods for restoration of the site+. i, de ,
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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.
1 A —
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.
stormwater site plan template—rev.10VJ72003 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. O
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�3. Control Flow Rates.
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4. Install Sediment Cgntrols. `
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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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r'P stormwater site plan template—rev.10/1/2003 '` '�
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 acttof pumping groundwater or stormwater away from an acttive cons ru tion site).
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11. klaintaiQ Best Manl,genpent Practices(BMP ). A ij
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12. Manap 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). ) 1
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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—rev.10/1/2003
9
b. Description of special requirements for working in or near environmentally sensitive areas.
1
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,settleabilit permeability,depth,texture,soil structure).
5. Construction Phasing.
a. Construction sequence
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 Manu ''f
Provide a proposed construction schedule.
II. Wet Season C st cti ctivities.
a. Propos t s a n onst activities.
b. Pr rp ed wet season construction activities for environmentally sensitive areas.
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.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. I
c. Waterways.
d. Runoff/Stormwater Detention Calculations
'' 2
005
stormwater site plan template—rev.10✓1/2003 t 10
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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.
// �r riga,
0 NER
( OR RIZ EPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
1
APR 2 9 2005
12
stormwater site plan template-rev.10/1/2003
r ' .
1",?.1., JEFFERSON COUNTY
+ DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368 APR 2005
, O�Q 360/379-4450 • 360/379-4451 Fax
K4--)::.." ..4
11V http://www.co.jefferson.wa.us/commdevelopment/
if
Stormwater Calculation Worksheet
MLA# 6 L Cl PROJECT/APPUCANT NAME: M,,,taC,.,1mud-
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 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet j `t 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 3/4 acres or more of
Construction site for structures O
_ sq/ft native vegetation to lawn or landscaped areas?
(.11,2.4,14{...,..,.....„_?....
Drainfield,septic tank,etc Nt;u. ,• --t., sq/ftCircle: Yes No I
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Well,utilities,etc. _( / sq/ft Does the project convert 21/2 acres or more of
7
Driveway,parking,etc r,/ �j�� native vegetation to pasture?
ssq/ft.
Circle: Yes CNO)
Lawn,landscaping,etc. _ 6) sq/ft
Other compacted surface,etc. er sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 3�� -�
sq/ft Cut y ..�i Fill (cu/Yd)
APPROVE
[over] STORMWATER PLAN
JUN 1 3 2005
stormwater calc worksheet—REV.10/1/2003 1
JEFFERSON ,.), Y
t)EPT.OF('O'vjJNl'.'11 .e,"
SIGNATURE:"
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) (-) sq/ft Structures(all roof area) 4 sq/ft
Sidewalks ' sq/ft Sidewalks - � sq/ft
Patios E. sq/ft Patios sq/ft
Solid Decks l:-)' sq/ft Solid Decks -6 sq/ft
(without infiltration below) (without infiltration below) ��f�I
Driveway /7/� q/ft s Driveway v sq/ft
/ . `)
Other `.. sq/ft Other sq/ft
r-
Total New i�/`' `� sq/ft Total Existing sq/ft
17/ :TOTAL NEW+TOTAL EXISTING* � `�`' 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: --1 %
Does the site have 35%or more of existing impervious surface? Circle: Yes Elo
11-\,
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
APPLICANT SIGNATURE
By signing the Stormwater Calculation 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.
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(LAipO ER OR AUTHO ED REPRESENTATIVE SIGNATURE „ < + (DATE)
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stormwater talc worksheet-REV.10/1/2003 # 2
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4�g ,cik6, JEFFERSON CITY ;�' it! (L` It:'
'A DEPARTMENT OF COMMUNITY DEVELOPMENT '
621 Sheridan Street• Port Townsend •Washington 983681'1 I ,l t'
360/379-4450 • 360/379-4451 Fax ; ��R 2 r`
�qlirING O� www.co.jefferson.wa.us/commdevelopment
JE-UeRSON COW" Y
Master Permit Application DEPT. OF _ _i_ r J
Project Description(incl,y�de separate sheets as necessary):
5I tit* k-k nv k PVIT
Tax Parcel Property 1 5' /, 0Number: f i o ., "1 o 0 —0 0 �.., . Size: `ifir
1 (acres/ are'
feet
Site AddrnzS and/or Directions to Property: Let 4/v\UT I 13 ;�gl`.'I Y IN! D,ry t Vim- ,A} ,.U�
Property Owner(s)of Record: ., 'WktE.I d �r li t�lrez h 1i tl ems ''t
Telephone: , _ 7 1'7-(4 cS t1`j Fax: o•„ I.
Mailing Address: I IS s \it _1� Po tet,t) LOA- S
Applicant/Agent(if different from owner):
TelephoneOliv) R 7z7ee, / ,.-,
Fax:( r) (4_'3 l -(J 741 email: hare Ld rrO 6,xbie r
Mailing Address: j* PSI � 1( : t l� P 1�R (-P i-)T l :• z. ) R g-310 5 Co/1t
What kind of Permit?(Check each box that applies)
')4,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 ❑Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular 0 Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑Change of Use ❑ Long Plat**
Li Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**XStormwater Management ❑ 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:
/ ESIGNAT ON OF AGE T r L
I hereby designate LA 1 e4'\,I /_-j I k-t to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE //G( _---p7-f/.7
Date: /-f T- G;.
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 attorney'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.A and right of entry to this property shall be requested and shall occur only during regular business
hours.Signature:' yi,74,./
tom —r —
Date: '/ _�� 5
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfe le re ponsibili for adhering and plying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature:/ :.74
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:/ L/ --Axlei 0� >r. t o� G l� I ' Date: %5 J
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
04 \4 Eu.I lex ( )01 q1-4,Sys ( )
MAILING ADDRESS: j i3 Cite f e, V j eto 'rein — ---- _
CONTRACTORS LICENSE t I t4
NUMBER: 1t I; -------- - 'NUMBER,,
ARCHITECT/ENGINEER: P a E ( I i! FAX:( )
MAILING ADDRESS: 1 i \:t
APR 9 'h!:! 'l,_,'
Project Type: Frame Type: I Bathroom�;,,,N r N-ry ne: Type of Sewage Disposal:
41 New Wood ry Muril' ; rVF V.lP�t'ctir ❑ Sewer
❑ Addition ❑ Steel roposeci-- _,"" %Community System
El Alteration/Remodel ❑ Concrete Total: . Height: ❑ Individual System _
❑ Repair ❑ Masonry SEP Permit# el S-2-1
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat; Proposed: D- '4 Public
11.0c b1:.a,L. , „t yjtt 41,1 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 Li Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured I Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For OfftceUs' y -,, ';n:.. ",a{ t - c t A ;;
Current Proposed tW:A -. # o
Main Floor 1(, . ., ``yy a�ncy Review: hl ��� . ; �� � t "-
2Nu Floor r v s , F: xJ,
Vase fee ( � R
3`°Floor YAdditionaiFSectiori: �{ :� a M1}, ,x,r
Mezzanine: �� �' .�1 i t *d� Plan Check fee I toC)� k 1T ,
Heated Basement rid --�
Unheated Basement ;40"
Other Unheated -'glow r ,p - : �{,: :r' - ,, �„ /
a
•
Garage/Carport 'z { st ��
4$8 it3(3 T S 7 2 :.rS
Decks _�_. - r �' -, ri 'r .` e�" ,
�. Number': p-. - L r s. Yeti �e,.,,,,- t£ c r
l " ~ 'Number 6 h •I, =. ., ,,A ,- kL �,, 37 y
Other • ,Y;�r i `t w,.: r,
s ;� . ,
F � r x 1,_ s r
ESTIMATED COS..-•i-UIRED) , 1/..• ,.` �" , 4 ,
•Fair market val . all labor and materials fou .aC •fin I fr i �' M `'�' T
G:\PemvtCenter\FORM It: FORMS ter Permit Application 7-8-04.doc