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HomeMy WebLinkAboutBLD2005-00380 • BUILDING PERMIT • Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD05-00380 Received Date 06/9/2005 SITE ADDRESS: 66 GARDEN CLUB RD Issue Date 07/19/2005 NORDLAND, 98358 APPLICANT: DAVID W LOWE PHONE: SANDRA S LOWE PO BOX 97 NORDLAND WA 98358-0097 SUBDIVISION: GARDEN CLUB ACRES SHORT PLAT Block: Lot: 1 PARCEL NUMBER: 921092027 Section: 9 Township: 29 N Range: 01 E CONTRACTOR: CRANSTON CONSTRUCTION PHONE: 379-2730 PO BOX 944 PORT HADLOCK WA 98339 Contractor's License: CRANSCC070J7 Expires: 3/10/2006 PROJECT DESCRIPTION: ADDITION TO SFR CALL IN FOR THE REQUIRED_INSPECTIONS THAT APPLY TO YOUR PROJECT. SETBACKS: A7/ • UFFER: NVA Footing: :� S � ti y Foundation: VE/ '}/ If;ji1` 17' Stormwater FINAL Approval: Underground Plumbing: Underground Insulation:. Shear Wall : t9X /o/24/o5 Sheathing: Framing: ;,yZ Plumbing: Mc m/< ttZ,w/A3u .�i/ :,/-q c Propane Tank/ Lines: Insulation: _I '444 .s D!C i//f/os# ViAs Sheetrock: Septic Sytem Final Approval (If not on sewer): Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: UL4—'1`1)—(b Fib 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 SPECIAL CONDITIONS FOR CASE # BLD05-00380 • 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.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 3.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 4.) MANDATORY MEASURES FOR COASTAL SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 5.) 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. 6.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 7.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 8.) 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). • 9.) Maximum lot coverage is not tdexceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 10.) The building height is not to exceed 35 feet. 11.) Setback from the private access easement right-of-way is no less than 20 ft., setback from the Garden Club Road right-of-way is no less than 20 ft.side and rear setbacks are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more restrictive setback shall apply. 12.) 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. 13.) 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. I:\F_B LD_Perm it_B uild ng.rpt 10/29/19 eUILDING Reviewiew Ty 354 PERMIT APPLICA1 N ML Review Ty I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00380 Received Date: 6/9/2005 SITE ADDRESS: 66 GARDEN CLUB RD NORDLAND, 98358 OWNER: DAVID W LOWE PHONE: SANDRA S LOWE PO BOX 97 NORDLAND WA 98358-0097 GARDEN CLUB ACRES SHORT PLAT SUBDIVISION: Block: Lot: 1 PARCEL NUMBER: 921092027 Section: 9 Township: 29 N Range: 01 E CONTRACTOR: CRANSTON CONSTRUCTION PHONE: 379-2730 PO BOX 944 PORT HADLOCK WA 98339 Contractor's License CRANSCC070J7 Expires 3/10/2006 REPRESENTATIVE: RANDY CRANSTON PHONE: (360) 379-2730 PO BOX 944 PORT HADLOCK WA 98339 PROJECT DESCRIPTIOP ADDITION TO SFR TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP ADD MAIN: 2,806 VALUATION 110,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE:, OTHER: SHORELINE: CONST TYPE:. GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 0 Prop: 0 Total: Total: l Routing Date: /'-ç.... 1 �f _ 2 IPP Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,055.35 BAC 06/09/05 73264 APPROVED Plan Check $685.98 BAC 06/09/05 73264 State Building Code $4.50 BAC 06/09/05 73264 JUL 1 9 2005 Potable Water Application $53.00 BAC 06/09/05 73264 . •fferson County Planning Total: $1,798.83 & Building I - artment il 4Ar FOE_ F¢EP S �� A . STORMWATER SITE PLAN SUBMITTAL TO: JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street•Port Townsend• Washington 98368 360/379-4450. 360/379-4.451 Fax http://www.co.jefferson.wa.us/commdevelopment/ MLA: To be assigned 4.6 PROJECT/APPLICANT NAME: David&Sandy Lowe Residence,40Garden Club Road,Nordland Where the question calls for depiction on a site map, the applicant chooses to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate storm water 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. The site is an 2.42 acre [105,305 square feet] rural parcel that is previously improved. Existing improvements consist of the following approximate square footages: • Residence of 2,336 square feet • Cabin of 820 square feet • Garage of 1,056 square feet • Storage Shed of 240 square feet • Well house of 16 square feet The proposed improvement consists of the construction of a 470 square foot addition to the single- family residence. Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. The site has a sloped lot of 3-20 percent slopes, with predominately first order growth. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. The site has predominately first through third-order growth. 4. Describe the existing soils. Indicate soil type on the site map. The existing soils consist of gravelly-sandy loam of the "Whidbey" [WhC]series of level to sloping soil on glacial terraces. This soil is of"well drained to moderately well drained"[Je er ounty Soil Survey]. It is of the family of mixed mesic soil series formed in_glae• ,,uZ vash,nn! iai s and terraces. APPROVE _- ' i .l i 3 STORMWATER PLAN � _ g 2005 JUL 14 2005 rN C�,o�t,TY C:\Documents and Se,ings\toma\De f\ MElYom's\.Stormwster Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 dFFt OF( 1! .Y' N � ti.0 SIGNATURE: )1 5. Describe the existing site hydrology(i.e.,drainage; behavior of water on the site—above,below,and on the ground). Indicate existing storm water 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. This soil is well drained. Permeability is moderately rapid above the cemented layer. Run off is slow to medium and the hazard of water erosion is thus slight to moderate. 6. Describe any excess levels of noise generated by the proposed use or activity: The proposal is for a single-family residence, with commensurate ambient noise associations as with the existing single family residences. The owner does not have any other excess noise producing activities. 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. None defined. 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.). Adjacent properties consist of rural single-family residential uses, on large-lot land bases. Public rights-of-way from light-bituminous type paved roads. Permanent Storm water Control Plan This portion of the Storm water Site Plan consists of the selection and installation of the appropriate storm water control BMP's 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. Please see application submittals for these calculations. 9. Describe the developed site hydrology, as proposed. Indicate whether storm water will be fully dispersed (i.e., per BMP 15.30 in the Manual) or, if not, what types of storm water 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. The construction of the residence will provide channeled roof flow via downspouts to direct ws to the surface grassed areas for transpo-evaporation, and natural infiltration. Driv urfac rades will direct water to the downhill side to achieve the same effect. The.dispersion there-from is bio- filtration medium of lawn and field grasses. Due to the permeability of the sjls;and dist nc om the property lines,full dispersion is experienced. } 200) • yY C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuf\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 • 10. If the project requires the use of storm water treatment facilities, describe the types of storm water 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.] No storm water treatment is necessary. 11. Describe the performance goals and standards applicable to the project. All storm water is controlled so as to not create erosion or off-site migration. The nature of the soils and the size of the parcel are significant contributors to this goal. 12. Describe the flow control system. The construction of the residence will provide channeled roof flow via downspouts to direct flows to the surface grassed areas for transpo-evaporation, and natural infiltration. None will migrate off- site. 13. Describe the water quality system. None is proposed or required of this proposal, as the rainwater path does not have contamination contribution during the process of the hydrological cycle. 14. Describe the conveyance system analysis and design. None is proposed due to the low rainfall statistics of the area, and due also to the size of the property, and also due to the proposed "best management practices"program to be instituted. 15. Describe the source of fill material; physical characteristics of fill material, and deposition of excess material. House foundation excavation material will be primarily re-deposited around subject addition to the residence, and back-graded to form a slope away from the residence. 16. Proposed methods of placement and compaction consistent with the applicable standards of the International Building Code,2003 Edition. Heavy machinery use will provide primary redistribution and compaction. 17. Describe the proposed surfacing material. Yard area around the house will be seeded with grass and contain traditional landscaping plantings of the owners choice. 18. Describe methods for restoration of the site. None required, as site for residence does not require therremoval of any major Iandsc ping or trees. The owner may choose to increase the number of trees with additienat75Thn ng of sa C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuff\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 • 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. Not applicable for this proposal. 20. List here and include any special reports or studies conducted to prepare the Storm water Site Plan. Jefferson County Soil Survey, United State Department of Agriculture Soil Conservation Service, August, 1975 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. Sewage Disposal Permit SEP75-00097, Jefferson County, September 23, 1975 EES by Private Contractor, Jefferson County, May 05, 2003 CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMP's 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 Storm water Pollution Prevention(SWPP)Best Management Practices(BMP's)Packet for guidance,particularly with rural residential development. SECTION I-CONSTRUCTION SWPPP NARRATIVE 1. Construction Storm water Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMP's 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). Required Elements-Construction SWPPP: A. Mark Clearing Limits. Minimize limit of land clearing to the residential site westerly side of the residenceonly, and marking[flagging]equipment operation zones. B. Establish Construction Access. Via the existing roadway access point to the subject property, construction,access w•l use MP C105 "Stabilized construction entrance" to control vehicle and machinery ire displ cent t of on-site soils to any off-site roadway. Wash-down of vehicle tires on-site will fur1( co trol uch occurrence during wet days. J; _ g l C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuff\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 C. Control Flow Rates. BMP C121 "Mulching" will be implemented to filter any and all downstream water flow, and thus stabilize the flow rate. D. Install Sediment Controls. While limiting the cleared area for construction, the applicant may install a silt fence at all "downhill" areas per BMP C233. E. Stabilize Soils. The applicant proposes to use BMP C121 "Mulching"to stabilize exposed soils that are subject to erosion, where applicable. F. Protect Slopes. The applicant proposes to use "surface roughening"BMP C130 and soil stabilization with BMP C121 "Mulching" at sloped areas with a ratio of 3:1 horizontal to vertical and greater during construction, and until permanent vegetative growth is established or an "artificial" ground cover such as crushed rock is applied G. Protect Drain Inlets. None exist on subject site. Jefferson County maintains a drainage ditch on the east side of Flagler Road which is west of the subject property. H. Stabilize Channels and Outlets. No temporary or permanent on-site channels or ditches exist or created to control runoff. However, since the proposal consists of a basement grade that is below the finished grade outside of the foundation, a small channel will be created during construction to allow drainage of the foundation excavation which will likely require the use of BMP C209 and mulching BMP C121 until foundation backfill is completed I. Control Pollutants. No vehicle or machinery maintenance is to be allowed on-site over impervious surfaces, and contractor's equipment will be required to not exhibit hydraulic oil or fuel leakage prior to storage or use on the site. J. Control De-Watering (the act of pumping groundwater or storm water away from an active construction site). Since the proposal consists of a basement grade that is below the finished grade ortside, of the foundation, a small channel will be created during\construc ion- Ilow- drai `ge c f the foundation excavation which will likely require the use`of BMP g�C209 and mu MP C121 until foundation backfill is completed 3a1 - 9 1`, \ 1 1 "y t J C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuff\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 K. Maintain Best Management Practices(BMP's). The owner is to supervise contractors to insure that BMP's are maintained to their respective functional design. L. Manage the Project. Construction is to be phase to prevent transport of water runoff or sediment, and limiting work during wet conditions where there may be a negative impact. Daily inspection and maintenance of systems is proposed 2. Adjacent Areas. A. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands,residential areas,roads). None to be affected B. Description of the downstream drainage path leading from the site to the receiving body of water (minimum distance of 400 yards). The proposed project will not result in or create off-site/downstream drainage paths. Jefferson County roadway ditching along Flagler Road parallels the shoreline, and is located on the westerly area near the subject property. Any off site migration, though not intended, would get "captured"by this open ditch, and transported eastward, downhill,from the site. The applicant does not know what termination measures Jefferson County has provided for this ditch. 3. Environmentally Sensitive Areas. A. Description of environmentally sensitive areas that are on or adjacent to the site. None of record B. Description of special requirements for working in or near environmentally sensitive areas. None of record 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, settle ability, permeability, depth, texture, soil structure). Analysis of soil characteristics and topography of this site coupled with the proposed project scope do not indicate any erosion problem potential based upon the soil type data of record and the minimal intrusion of soils for this project. 5. Construction Phasing. A. Construction sequence - - The applicant is to mark clearing limit area, establish const u on access, f Linda ion excavation, install proposed BMP's per plan, construct project, and tIgneagple ent he permanent plan. �j�11V h"`•. C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuft\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 B. Construction phasing(if proposed) Project to be started during the dryer period of the seasons, likely June. 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). A. Provide a proposed construction schedule. Begin project in June, and conclude by September. B. Wet Season Construction Activities. 1) Proposed wet season construction activities. None anticipated. 2) Proposed wet season construction activities for environmentally sensitive areas. Not applicable for this proposal. 7. Financial/Ownership Responsibilities. A. Identify the property owner responsible for the initiation of bonds and/or other financial securities. The applicant, and any contractural arrangement with the builder. B. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. The building permit process and site inspection sequence is conducted by Jefferson County. 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. A. Sediment Ponds/Traps: Not applicable B. Diversions: Not applicable C. Waterways: Not applicable D. Runoff/Stormwater Detention Calculations: Not applicable SECTION II-EROSION AND SEDIMENT CONTROL PLAN Sediment and erosion control measures may be depicted on the master land use application plot plan, a stormwater site plan, and/or a separate Construction SWPPP site plan. This is a checklist to ensure that the following are depicted on a site plan: 1. General. a. Vicinity Map b. Jefferson County Approval Block c. Erosion and Sediment Control Notes _ g 2005 \ JUi� 2. Site Plan. a. Legal description of subject property, C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuff\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 Final Corrected Plan Submittal If the project includs 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/off,.._ David&/or Sandy Lowe, landowner[s][or representative] &Date -_- \ 09 VOS k '.. C:\Documents and Settings\toma\Desktop\Tom's Cabinet\Stuff\Tom's\Stormwater Apps\Stormwater Site Plan Submittal-Lowe.doc6/7/2005 -4�S©N c06 JEFFERSO,UNTY . /'.w ' I DEPARTMENT OF COMMUNITY DEVELOPMENT ` `.4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �� 0 www.co.jefferson.wa.us/commdevelopment SANG Master Permit Application MLA: 05"354- Project Description(include separate sheets as necessary): 401,/7701•./ To ,4 S/NGLE GAN/2rY , ES/2:7ENCa Tax Parcel Property Number: 2 0 9 2 O 2 z Size: 2.42AG/o3 Fos (acres/square feet): Site Address and/or Directions to Property: �� ���I�EN _CLv6 �20AD Property Owner(s)of Record: D.4V/D W. e $ 4N,D.eA S. LOWE' Telephone: Fax: email: Mailing Address: P.0. 80X 9' Applicant/Agent(if different from owner): G/Q4-NS70N COA/STRUC 77DA/ CO. Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies)------- 1 A Building ( 0 Vari nce(Minor, Major or Reasonable Economic Use) 11 Demolition Permit ---•-- ** ,... ❑ Con itional Use[C(a),C(d),or C] Ib Single Family ,� Il Disc etionary"D"or Unnamed Use Classification ❑Garage Attached/Detached 5 0.S al ** ❑ Manufactured Home i f;°�'';;, _ 'j fj�l� pe � Use(Essential Public Facilities) ❑ Modular I Bou ary Line Adjustment ❑ Commercial* - d Sho Plat 0 Chan a of Use 1 ih - ,a--0-Bindi g Site Plan** g " _ 'ID.Long lat** ❑Address ❑ Road Approach _ _—= --B-pranned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater 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: D I NATION OF AGENT I hereby designate k a i- i. 0 y to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE I` Date: ill C -- (7"? - t:' ,j 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 wa accrue against Jefferson unty as a result of or in consequence of the granting of this permit. I further agree to prolde acces and right of entry to Jeff on County and its employees,representatives or agents for the sole purpose of application review and any requl 'd later n pections.Access a d • t of entry to this property shall be requested and shall occur only during regular business hours. I it-'i Signature: Date: v C cc,/ - G' .! 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 potenti "take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson my makes no assurances to the applicant that the actions that will be undertaken because this permit has been i ued 'II not violate the ESA. y individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if y are• compliance wi the J fferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfer e r nsibility foadh riaito and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: \ (, IF- , Date: � � � � (<i G:\PemutCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 0 , 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: -- ill-- '?O(—23g 0 GENERAL CONTRACTOR OR MANyFACTURED HOME INSTALLER: -. PHONEI FAX: _c Qa\S�OJ CO o3s� '?C"�(f:P�N --— (- 1) 7Q 43p ( ) MAILING ADDRESS: � �-` � lit 9-i. - ' ca 1_06, Eiv iL: lit--" `, ii:; CONTRACTOR'S LICENSE WAINS NUMBER: Oitifl 561.-.0795i NUMBER ARCHITECT/ENGINEER: I PHONE'' ) FAX:( ) MAILING ADDRESS: 4` —� EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New a Wood Existing: ❑ Sewer • Addition ❑ Steel Proposed: $ Bank 1.7 Community System ❑ Alteration/Remodel 0 Concrete Total: Height: ■ Individual System O Repair 11 Masonry SEP Permit# 0'3-1/OZ ❑ Demolition 0 Other: Bedrooms: Water Supply:s4,2g7 Existing: Setback: • Private well i i Two Party Type of Heat: Proposed: 41' 0 Public Total: Name of System: If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: O Underground Tank Li Above ground Tank Size of Propane Tank: ❑ Heat Stove 11 Cook Stove ❑ Woodstove C7 Fireplace Insert 0 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 For Office Use Only Current Amount Main Floor 2 3 3 a7 2 eU /}Consistency Review: O O 2""Floor ✓ Base fee: (D SS '7 5. 3f0 Floor Additional Section: f k „. Mezzanine: ----- - _. Plan Check fee: (A5 r R - Heated Basement t I-- --- - ----_ State Surcharge fee: 1 t Unheated Basement' zf tI Pot Water Review fee: : -"',L ` - Other Unheated I i i 911/Rd Approach fee: Garage/Carport f TOTAL: $ ( gg! -3 x.. 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