HomeMy WebLinkAboutBLD2005-00394 fkUILDING PERMIT APPLICATION ML view ype:
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00394 Received Date: 6/13/2005
SITE ADDRESS: 1221 LEMONDS
QUILCENE, 98376
OWNER: STEVEN G CARUSO PHONE: 206-406-4647
JANET P CARUSO
PO BOX 519
EDMONDS WA 98020-0519
SUBDIVISION: Block: Lot: T4+
PARCEL NUMBER: 601032006 Section: 3 Township: 26 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
�Atel d lCam:
PROJECT DESCRIPTIOP DEMO OF CARPORT, SFR & CABIN \t / `"'` ect S4°rir—
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM MAIN:
VALUATION ADD'L: HEAT TYPE:
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK: 90
BANK HEIGHT: 2
SEWAGE DISPOSAL: APPROVE)
WATER SYSTEM:
BEDROOMS: BATHROOMS: JUL 2 1 2005
Exist: Exist:
Prop: Prop: Air fferson ' Planning
Total: Total: ' Buil,i.', /artmen
40
Routing Date:
(0/45>6 5 JEFFERS• ' I I •41 D
BUILDING PLAN REVIEW
Type - Amount Paid By: Date: Receipt: V A jpproved/Date, SUBMITTED
Permit $49.00 BAC 06/13/05 73367
State Building Code $4.50 BAC 06/13/05 73367 I APPROVED AS NOTED
Total: $53.50
❑ REJECTED
Date 7/r/0( Revieweh=
•
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00394 Received Date 6/13/2005
SITE ADDRESS: 1221 LEMONDS Issue Date 7/21/2005
QUILCENE, 98376
APPLICANT: STEVEN G CARUSO PHONE: 206-406-4647
JANET P CARUSO
PO BOX 519
EDMONDS WA 98020-0519 T4+
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 601032006 Section: 3 Township: 26N Range: 01W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, STEVEN G CARUSO PHONE: 206-406-4647
if different: JANET P CARUSO
PO BOX 519
EDMONDS WA 98020-0519
425-774-4176
PROJECT DESCRIPTION: DEMO OF CARPORT, SFR & CABIN PR Le-tier 6.) 11 Y0+12-dein ls-Ci
4
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE. US i� vssickci
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 7/21/2006.
4/2.7/0.
REQUIRED INSPECTION:
"1444-
Fina!Approval:Siver,, )71-11+0.AC rt.J ,14,,q,.- +SJ��
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
• •
SPECIAL CONDITIONS FOR CASE#BLD05-00394:
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on July 21, 2005 for the potential presence of Environmentally
Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC).
After an initial Geographic Information Systems mapping review and an investigative site
inspection, the following ESAs were confirmed to be present on the subject property:
Shoreline conservancy; SUSC aquifer recharge area; coastal SIPZ.
2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
formations that allow percolation of the surface water into the soils and the underlying
zone of saturation. Aquifers are geologic formations that contain sufficient saturated
permeable material to yield significant quantities of water to wells and springs. Aquifers
serve as the source of drinking water within most of the rural portions of Jefferson
County.
3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
4.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
5.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002)that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater
sources within 1000 feet.
6.) Critical Aquifer Recharge Areas may require special protection measures to mitigate
water quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs) and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
7.) 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.
• •
8.) 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.
9.) 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.
10.) 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.
11.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
12.) The applicant is proposing to decrease the net impervious surface coverage by 628
square feet and proposing 600 square feet of land disturbing activities.
13.) 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.
14.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(1)(b)(i).
15.) The site plan as submitted with the building permit application on June 13, 2005 has been
reviewed for consistency under the UDC, and has been approved by Jefferson County
Department of Community Development. Any modifications, changes, and/or additions to
the stamped, approved site plan dated July 21, 2005 shall be resubmitted for review and
approval by Jefferson County Department of Community Development.
16.) This approval is for a demolition of carport, single family residence, &cabin only. Any
future permits on this site are subject to review for consistency with applicable codes and
ordinances and does not preclude review and conditions which may be placed on future
permits.
17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
• •
18.) 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).
19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
20.) The building height is not to exceed 35 feet.
21.) Minimum setback from Lemonds Drive right-of-way shall be 20 feet. Minimum side yard
setbacks shall be 5 feet. Minimum setback from shoreline top of bank shall be 45 feet per
submitted site plan.
22.) 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.
23.) 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.
24.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
25.) A Declaration of Restrictive Covenant has been recorded on October 28, 2004 under
AFN 490992. The purpose of the covenant is to tie the parcels together for septic and
building purposes only.
26.) An address of 1221 Lemonds Drive, Quilcene has been assigned to the parcel. Lemonds
Drive is a private road (P87).
27.) The proposal was reviewed for consistency withe the Shoreline Management Master
Program Section 3.402.5 and found to be consistent. The proposal is (1)to demolish
existing SFR, cabin &carport, (2) does not exceed 35 feet in height, (3)does not involve
over-water construction and is located landward of the OHWM, (4) and meets all required
setbacks as set forth in said SMMP.
28.) A septic permit (SEP04-0210)was approved on November 19, 2004. A building permit
(BLD05-0396)for a single family residence and a permit for a garage (BLD05-00398)will
be issued with this permit.
I:\F_BLD_Permit_Propane.rpt 10/29/19
. • •
(izti ,,�. Olympic Region Clean Air Agency
l 2940-B Limited Lane NW JUN 13 1005
�J Olympia, WA 98502
,,, O RCAA �" (360) 586-1044 or 1-800-422-5623
4, , Fax: (360) 491-6308 www.ORCAA.org j
,
- "•ifiif ISOM•MASO
Notification of Demolition Permit
It is unlawful for any person to cause or allow the demolition (or major renovation) of any structure unless all asbestos-
containing materials have been removed from the area to be demolished. Work shall not commence on an asbestos project
or demolition unless the owner or operator has obtained written approval from ORCAA. A written application for a
demolition shall include a certification that there is no known asbestos-containing material remaining in the area of the
structure.
Project Site Address: I Zz! LEM 0k 1 S bp., County: 3 AFL-1 so&D
City: a(.t I LGL-A.; State: WA Zip:ci S 7(0
Starting Date: Completion Date:
*(There is a 10 working day advance notification period from receipt of permit application)
Property Owner: STEvF—) (1APL.SO Telephone: 2-o(v- 4C(..,-- 4(47 Fax:42-9-7 74-4 17(-'
Mailing Address: P.0. bo,, S`ci
City: Fd PI-070 p S State: W A Zip: 9Qz 2-c)
Demolition Contractor: CAAi/Jai2-- State License#:
Mailing Address:
City: State: Zip:
Contact Person: Telephone: Fax:
YES NO
•<' Demolition by Wrecking or Dismantling? ($25.00 fee) check# nonrefundable
Training Fire Demolition? (If yes, attach fire department request for training fire)
'< Renovation, Alteration,Remodeling, Maintenance, or other Construction?
Asbestos found or suspected*
*An ORCAA "Notice of Intent to Remove or Encapsulate Asbestos" form and appropriate fee must be submitted prior to any asbestos
removal work. Asbestos removal projects involving demolition must be preformed by a Certified Asbestos Contractor and all friable or
potentially friable asbestos must be removed before any demolition begins. Refer to ORCAA Regulation 1 Article 14 for additional
requirements that may apply.
Asbestos Survey Completed by
AHERA Certified Inspector =j EPci'J .- 1 AY La-- / - -? L k/ -• ( Vi'/c))¢-
Certification # O 1 Z 1 e Z R O Z.
This approved permit must Enclose$25 Certification of the Asbestos Survey must
be available at the job site Processing Fee accompany this form
F:\COMMON\Forms\asbestos\DemoPermit.doc
Rev.10/22/02
0 /20/2004 16:37 FAX 360 491 6308• ORCAA 2001
•
Date: Initial
Initial
Amended: ❑ ,a�i3�� e V 2940 5 Limited Lane NW D
�� 1 ��, Olympia, WA 98502
Completion:❑ f / sl Phone: (360) 586-1044 AUG 2 0 2004
`\; O RCAA .1' Fax: (360)491-6308
Annual: ❑ $500 "•re,.m,i.si_r�µ^, V�
'../ www ORCAA.orq 4°i`Yj'1'H"Y
Permit Application for an Asbestos Project
A. Project Type: 1 bcstos Removal 2. LI Renovation r3. U Maintenance
4.❑ Encapsulation 5. Demolition 6. ❑ emergency 7. ❑ Other: —
B. Property Owner: // � � Fop 4 r 7��-4-/41t 7�(r
Si L� )V 6-A-�(,tsd Phone:(ZO(o) ! -4( 4
7
Property Owner's ` 1`
Mailing Address: Pa • ,� 1 q City: Eb/11.0Jl.?DS State: WA Zi
C. Asbestos Contractor: p���
G.--, � Contractor Owner/CEO:
Mailing Address: Phone: ( )
City: State: Zip: fax: ( )
D. Site Address:
I ZZ I 1Mavbs be4 Ya Ciitty� [ill I, tar State: WAN- Zip.• f vc'77
ContactProject Manager or - Ja� C JT`l�-'t�j� q` �
Person: Phone:(2Ce) ~` e4
E. IrAsbestos Survey or No.of Structures: Date Asbestos Survey Conducted: W Asbestos Found?
❑ Marl Presumed: I
l S I. / es
❑ If No,Attach Survey
AHERA Building AN ARERA SURVEY IS REQUIRED BEFORE ALL DEMOLITION Certification No.:
expiration Date:
Inspector Name: HRoleas
-1•00../I Tfiyt, ( kL,i ,iX)G.) 4012.( B og Jam,• Zt, 2sx ,
F. Demolition No_of Structures: Start ci / LI Training Fire(List Fire Dept.as demolition contractor below)
Information; I Date: `I�J/o4 ❑ Ordered Demolition(attach copy of Order)
Demolition Print nainnhoer,ommr mailing iiiiilrwrie in a-1a r�.k,jk^,if ,;^sbr.,�,.,.i. ffr... Int.,Contractor: 5E-F ,/Ow Phone:(20(v)4CG— .--7
G. Asbestos No.of Structures:(sec Start Date: Completion Wk.Days: M T W Th F Sa Su
Project back if>1) 1 r /z{�/ Date:(34 Hours: _ i(Ain
Information: `
Will all asbestos material be removed by
Total Quantity to be Removed: 3 - Square Feet Linear Feet project com letion3g Yes ❑No
Thermal System Insulation: 3oiler/Furnace Ins. U Duct Ins. LI Pipe Ins. Other.i'{'Q`-1- i l - .-
Surfacing Mat'!: ❑Fireproofing U Paints I Li Plaster ,i U Textured Coatings Other.
Misc.Mat'!: U Cement Bd. Li-Cement Pipe Li Flooring Mat'1 Roofing Mat'! Other.
H. Asbestos/Demolition Project Categories: • cation Waiting Period NONREFIINDa•LP..
1. esidential Dwelling Asbestos Remov Prior Notice /'
• 2_ = emolition 10 Working Days I
3. less than 10 linear feet or less than 11 stl}let 31
1 Prior Notice
4• ❑10-259 linear feet or 11 - 159 square fee 91'2.0 0 10 Working Days S 100 i
5. 0260-999 linear feet or 160-4,999 squ 10 Working Days $250
6. LI 1,000-9,999 linear feet or 5,000-49,999 square feet _ 10 Workin D ys S500
77010.000+linear feet or 50.000+square feet 10 Working Days, $1.000
8_ UAnnual Permit(Limited removal,additional permits,.contact OR_CAA) Prior to start of New Year $500
9. UEmergency Project _ Prior Notice $50
10. L-IAmendments(no fee for 1 e`and 2"d amendment) Prior Notice $25
L I do hereby certify that the information contained in this notification.and supplemental data Payment recei. t : ♦:3/7r1:1(b!4
described herein,is to the best of my knowledge accurate and complete. I shall not cause or allow Reviewed dot • C
any asbestos pro et or demoliri activities to begin until the appropriate waiting period has Reviewed by.
elapsed.
Permit N bet• �J^y�y'��
SA el/c4.
uate�lied notification to applicant: 1 d Q.—
Sigttantre: Date: L /
( For .,... nee With Regulation 1,Section 14-Asbestos
Print.acne: CAA dt:::1 RcpresentinR: Agency Use Only
Rev.07/07/04
• z004 16:37 FAX 360 491 6308 • ORCAA • [J 002
The Olympic Region Clean Air Agency is the local air pollution authority for Clallam, Grays Harbor,Jefferson,Mason,Pacific,
and Thurston Counties. The Olympic Region Clean Air Agency's Regulation 1, Article 14, requires advance notification be
submitted to the Agency, on Agency-provided forms, for any asbestos project and for any demolition project, regardless of
asbestos content, involving any structures. Notices of Intent should be mailed or hand delivered to the Agency(address on
reverse side) with the appropriate project fec. An Agency representative will review the notification, and if it is completed
correctly a copy will be returned by mail or fax within 3 to 5 days to information provided in box C and box J. The returned
copy will be your valid notification_You must have an approved permit prior to job commencement
J. Demolition C onhac r. / Owner/CEO:
Mailing Address: PO- ) 19 Phone: ) 4'96 f 447
City: R]'nktrN D 5 State: WA Zip: 1 Sa2.-O Fax: (` .Z 774- 41 740
GUIDELINES FOR SUBMITTING AN APPLICATION TO PERFORM AN ASBESTOS PROJECT
Enter all applicable information accurately and completely. Incomplete Notices of intent will be returned_
Box A.Check all appropriate project type.
Box B.Enter the legal property owner information.
Box C. Enter the asbestos contractor information, or "not applicable" (N/A) for demolition projects when no asbestos-
containing materials are present. For a Residential Dwelling asbestos removal project, list the property owner doing the
asbestos removal(include property owner's mailing address).
Box D, Enter the asbestos removal or demolition site address. For a Residential Dwelling asbestos removal project where the
property owner's mailing address differs from the site address listed in Box D. a letter must accompany the Notice of Intent
verifying that the structure located at the site address is currently being used as the property owner's domicile. Multiple
asbestos/demolition projects involving more than one structure must be submitted in accordance with the ORCAA Regulation
1, Section 14.05(a)(8).
*Residential dwelling (ORCAA Article 14, Section 14.03 Definitions) means any non-multiple unit building
containing space for uses such as living, sleeping preparation of food, and eating that is owned, used, occupied, or
intended or designed to be occupied by one family as their domicile.This term includes houses,mobile homes,trailers,
houseboats,and houses with a`mother-in-law apartment" or"guest room." This term does not include structures that
are demolished or renovated as part of a commercial or public project. Nor does this term include any mixed-use
building,structure, or installation that contains a residential unit,or any building that is leased or used as a rental.
Box E. Enter the asbestos survey information or check material presumed(for asbestos projects only). An AI-ERA building
inspector must conduct an asbestos survey prior to any demolition project (i.e., the wrecking,razing, leveling,dismantling or
burning of a structure, making the structure permanently uninhabitable or unusable)_ A copy of the survey results shall
accompany the application_
Box F. Enter the demolition project information. If the structure is to be used in a training fire, list the fire department
responsible for conducting the burn as the demolition contractor in Box J. If the property owner has been ordered to perform a
demolition by a government official,submit a copy of the order from the appropriate official.
Box G. Entcr all asbestos project information or enter"N/A"for demolition projects with no asbestos removal required. All
multiple structure asbestos projects must be submitted with a work_rlan, map of the structures,complete site address, type and
amount of asbestos material Abe removed from each structure,AHERA asbestos survey,and wort(schedule.
Box H. Check appropriate project categories in boxes 1 through 8. Asbestos project fee does not include demolition project.
An additional S25.00 is required for a demolition project. Emergency notifications must be submitted with a letter from the
property owner explaining the necessity for the emergency. Emergency demolition notifications must be submitted with a
letter from an authorized government official or a licensed structural engineer documenting that the structure is in imminent
danger of collapse.
Box I. Sign the notification certifying the accuracy and completeness of the information provided on the form
Box J. Enter demolition contractor mailing information(on back).
Mandatory amendments are required for changes that increase the project type, job size category, the types of asbestos
materials to be removed and work schedule changes. A $25.00 proc= 91 na
amendments have no fee requirement).
For technical assistance,or inquiries concerning notification and amend;}',;t ;t$EAM& G��
APPROVED o r14C "
•
V
CONDITIONALL' P ROVED
JUN 1 3 2005 NOT APPROVED
FOR COMPLIANCE WITH 1
ORC GU !0
Rev.07/07/04 r•
trill!
eo� JEFFERSONJNTY ID
DEPARTMENT OF COMMUNITY DEVELOPMENT
lik:41.."1
'4 621 Sheridan Street• Port Townsend •Washington 98368 ,.
360/379-4450 • 360/379-4451 Fax
�.q ,o www.co.jefferson.wa.us/commdevelopment
G J U N 1 3 2005
Master Permit Application MLA: OS- aQ
Project Description(include separate sheets as ) ,
D c-t i-v ttvc.{,S G * G 1 ti
Tax Parcel (L'I C-1-3Z ( 4- /
Number: (C)f U Z.O ( C.) CZ' Pro Size:e Z•-' 7/ !G (cx SF �feet)
bp.../
/t = ' (acres/
Site Address and/or Directions to Pr perty: I Z2I .��. l / (L[`-0...S f .4-)A., 1bs7k.c.,
Property Owner(s)of Record: --�1�^1T } �; 4 -C:i
Telephone: :7 f Fax: L 7 tt tt-*
,y- F�1 7 � — �� email: �..�CZr�,t��v�.,G�,/)'1�C ��'
Mailing Address: I .O- }L %41 j;b t c> WA `- o
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑ 'ding 0 Variance(Minor,Major or Reasonable Economic Use)
,Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
❑Single Family ❑Discretionary"D"or Unnamed Use Classification
Garage Attached tached � ❑Special Use(Essential Public Facilities)**
`❑Manufactured Home 0 Boundary Line Adjustment
❑Modular 0 Short Plat--
❑Commercial* 0 Binding Site Plan**
Change of Use ❑ Long Plat**
❑Address 0 Road Approach ❑ Planned 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
El Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* El Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,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 provi access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any requi inspecti and right of entry to this property shall be requested and shall occur only during regular business
hours. -
Signature: A. 11/e-- L-,--- Date: ��C '�j
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' wi)l 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 y a n complian 4vith the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-trans I ibili adhering to and complying with the ESA. The Applicant has read this diOaiVer a signs and dates it below.
Signature:/ 4" 4-1 ;QZ/," Date: (ram C) C)
G:\Pe t# tCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
•NER BUILDER STATEMENT
ie signer of this ment doeshereby certify that they are the Owners of the parcel referenced herein,that they a not licensed contractors and that
ey will be assu r e res bility of the General Contractor for the proposed project.
(U�C; /
gnature: Date: >
ENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
(AILING ADDRESS: EMAIL:
ONTRACTOR'S LICENSE WAINS
UMBER: NUMBER -
RCHITECT/ENGINEER: PHONE ( ) FAX:( )
TAILING ADDRESS: EMAIL
rnred Type: I Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
!ew Wood Existing: 0 Sewer
Addition /❑ Steel Proposed: Bank ❑ Community System
Alteration/Remodel ❑ Concrete Total: Noi„ht• . .,Individual System
Repair ❑ Masonry —�-- SEP Permit# tt%Z f v
Demolition Other: Bedrooms: Water Supply:y:
Existing: Setback:
Private well ❑ Two Party
ype of Heat: Proposed: / Public
Total: Name of System:
f this is a Commercial Project you must answer the following:
lumber of Parking Spaces: Current Proposed: Number of ADA Parking Spaces:
lumber of occupants(includes owners,tenants,employees,etc) Current Proposed
BC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
f this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
3 Underground Tank ❑ Above ground Tank Size of Propane Tank:
] Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other
s this appliance being installed in a Manufactured/Mobile Home? Yes I No
Nhen applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
'fines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
'ncluding the reserve area.
Square Footage For'Ofiice Use-Only
Current Proposed Amount
Main Floor consistency R+evjotu:
?NU Floor
3f0 Floor Additional
Mezzanine: Plan Check fee:
Heated Basement tasu"Cltatp„l
Unheated Basement
Other Unheated z44
, , 5;a
•
Garage/Carport �, zlu,t r
Decks l!1Gnter' • S
Other C4 "`I xt
ESTIMATED COST(REQUIRED) ) 4 x
•Fair market value of all labor and materials foundation to finish
;:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc Ij4
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