HomeMy WebLinkAboutBLD2005-00419 all MLA05-09385'UILDING PERMIT APPLICA N Review Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00419 Received Date: 6/23/2005
SITE ADDRESS: 140 CLEVELAND ST
PORT HADLOCK, 98339
OWNER: KATHRYN G SEDLAK PHONE: 360 302-0156
6505 NE FIR ST
SUQUAMISH WA 983929777
IRONDALE AC TRACTS
SUBDIVISION: Block: Lot: T 22+
PARCEL NUMBER: 962700096 Section: 7 Township: 29 N Range: 01 E
CONTRACTOR: OLYMPIC RIDGE INC PHONE: 360-302-0156
15940 LINDSEY LANE
POULSBO WA 98370
Contractor's License OLYMPRI986NA Expires 8/1/2006
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr DEMO OF HOUSE AND GARAGE
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2003 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: __
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date: /'
(rnow/
O'er C� �
Type Amount Paid Bv: Date: Receipt: I�VeV V
State Building Code $4.50 INT 06/23/05 73401 A I p�L.l? V
Permit $49.00 INT 06/23/05 73401 AUG - 3 2005
Total: $53.50
Jefferson County Planning
& B ' • Department
3I
-(2_
•
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00419 Received Date 6/23/2005
SITE ADDRESS: 140 CLEVELAND ST Issue Date 8/3/2005
PORT HADLOCK, 98339
APPLICANT: KATHRYN G SEDLAK PHONE: 360 302-0156
6505 NE FIR ST
SUQUAMISH WA 983929777
T 22+
SUBDIVISION: IRONDALE AC TRACTS Block: Lot:
PARCEL NUMBER: 962700096 Section: 7 Township: 29N Range: 01 E
CONTRACTOR: OLYMPIC RIDGE INC PHONE: 360-302-0156
15940 LINDSEY LANE
POULSBO WA 98370
Contractor's License OLYMPRI986NA Expires 8/1/2006
OWNER, KATHRYN G SEDLAK PHONE: 360 302-0156
if different: 6505 NE FIR ST
SUQUAMISH WA 983929777
PROJECT DESCRIPTION: DEMO OF HOUSE AND GARAGE
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 8/3/2006.
REQUIRED INSPECTION:
FinalApproval: ilou5& 4 CPsz_s16E DEMhi-tS+NED 4 eEnnav;;+D . SRE
tyiyoS ty,ct
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#BLD05-00419:
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on July 27, 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:
conservancy shoreline;wetlands (shoreline); seismic; coastal SIPZ.
2.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
3.) 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.
4.) 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.
5.) 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.
6.) 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.
7.) 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.
• .
8.) 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.
9.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
10.) The applicant is proposing to create or add 1545 square feet of impervious surface and
429 square feet of land disturbing activities.
11.) 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.
12.) 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).
13.) The site plan as submitted with the building permit application on June 23, 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 27, 2005 shall be resubmitted for review and
approval by Jefferson County Department of Community Development.
14.) This approval is for a demolition permit 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.
15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
16.) Not more than two (2) 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).
17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
18.) The building height is not to exceed 35 feet.
19.) Minimum setback from Cleveland Street right-of-way shall be 20 feet. Minimum side yard
setbacks shall be 5 feet. Minimum shoreline setback from top of bank shall be 30 feet.
20.) 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.
21.) 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.
22.) Residential developers and individual builders shall be required to preserve shoreline
vegetation and reduce the associated risk of erosion during construction and any future
activity which may impact the stability of the shoreline.
23.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
24.) An address of 140 Cleveland Street, Port Hadlock has been assigned to the lot.
Cleveland Street is a county local access road (C578309).
• •
25.) A septic permit(SEP91-0547)was finaled on February 5, 1992. A road approach
(RAP04-0182)was approved on July 23, 2004. A boundary line adjustment
(SUB05-0005)will be approved once the building permits are issued. A building permit
(BLD05-0418)for a single family residence will be issued with the demolition permit.
26.) The lot was originally created through the Irondale Acre Tracts Subdivision on December
12, 1910 under AFN 31830 and amended on April 8, 1991 under AFN 339373.
27.) The proposal was reviewed for consistency with the Shoreline Management Master
Program Section 3.402.5 and found to be consistent. The proposal is (1)a single family
residence, (2) does not exceed 35 feet in height, (3)does not involve over-water
construction and is located landward of the OWHM, (4) and meets all required setbacks
as set forth in said SMMP.
I:\F_BLD_Permit_Propane.rpt 10/29/19
07/26/2005 15:04 FAX 360 491 408 ORCAA 421002 _
( , PERMIT# DO i
APPROVED_CL
44 1C eloNcl , CONDI 0 ALLY APPROVED
a \o Olympic Region Clean Air Age
�""� x 2940-B Limited Lane NW NO APPROVED
Olympia, WA 98502 FOR COMPLIANCE WITN
`•� URCAA � (360) 586-1044 or 1-800-422-5 ORCAA REGULATION
7wR�F•JffFiWSOM•HU„. 910' Fax: (360) 491-6308 . www.O
Up (V.1 S 4'tar-4-- c
Notification of Demolition Permit 17A Z
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: 140 Cleveland Street County: Jefferson
City: Port Hadlock State: WA Zip: 98339
Starting Date: _ Completion Date: _
• There is a 10 working day advance notification period from receipt of permit application)
Property Owner: Kathryn Sedlak Telephone: (360)598-3715 Fax: None
Mailing Address: 6505 NE Fir Street
City: Suquamish - State: WA Zip: 98392
Demolition Contractor: a�a Eiio l
6„V l,. }
State
,fLicense#: t QA t) Q j
Mailing Address: /O 1 (r air 4.-cw,LcE l.U-1 00'i
City: State: L � ZAP: -7 ?
Contact Person: Telephone: 760- 2.0 g (P(OO Fax: "7(9 -o rq)
YES NO
X 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 Raanovc or Encapsulate Asbiztos" 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 RENE A. LAMARCHE,JR
Certification# 1015741
This approved permit must Enclose 525 Cettiticalion of the Asbestos Survey must
be available at the job site Processing Fee accompany this fonn
RECEIVED p -
F:\COMMON1Fonns\asbestos\DemoPermit_doc A
Rev.10122J02 JUN 2 5 Zoos
ORCAA .0.7174X1
'11\4
Date: Initial cto�cLt Date Application Received
os,Amended: ❑ N'<9%14 �1_.:4.4. 2940 B Limited Lane NW
° , -•/ " % Olympia, WA 98502ebi
Completion: ❑ Phone: (360) 586-1044 NORCAA Fax: (360) 491-6308 JUN V) ?_no5
Annual: ❑ $500 - www.ORCAA.orq
Agency Use Only
Permit Application for an Asbestos Project _
A. Project Type: 1. U Asbestos Removal 2. ❑ Renovation 3. ❑Maintenance
4. ❑ Encapsulation 5. I:I Demolition 6. ❑ Emergency 7. ❑ Other:
B. Property Owner:
KATHRYN SEDLAK Phone:( 360) 59$-3715
Property Owner's
Mailing Address: 6505 NE FIR ST City: SUQUAMISH State: WA Zip: 98392
C. Asbestos Contractor: Contractor Owner/CEO:
Not Applicable(N/A/)See attached survey.
Mailing Address: Phone: ( )
City: State: Zip: Fax: ( )
D. Site Address:
140 CLEVELAND ST City: PORT HADLOCK State: WA Zip: 98339
Project Manager or
Contact Person: E. J. KLINKER Phone:( 360) 302-0156
E. I:l Asbestos Survey or No.of Structures: Date Asbestos Survey Conducted: Was Asbestos Found?
U Mat'l Presumed: 2 5/12/2005 Li Yes
0 If No,Attach Survey
AHERA Building AN AHERA SURVEY IS REQUIRED BEFORE ALL DEMOLITION Certification No.: Expiration Date:
Inspector Name: PROJECTS
RENE A.LAMARCHE,JR 1015741 5/11/2006
F. Demolition No.of Structures: Start U Training Fire(List Fire Dept.as demolition contractor below)
Information: 2 Date: ❑ Ordered Demolition(attach copy of Order)
Demolition Print name here;enter mailing address in box J on bark ofjorm.Ljtmuvng bract enter name offrre department here
Contractor: Phone:( )
G. Asbestos No.of Structures:(see Start Date: Completion Wk.Days: M T W Th F Sa Su
Project back if> 1) N/A N/A Date: N/A Hours: N/A
Information:
Will all asbestos material be removed by
Total Quantity to be Removed: Square Feet Linear Feet project completion?0 Yes ❑NO
Thermal System Insulation: U Boiler/Furnace Ins. Li Duct Ins. U Pipe Ins. Other:
Surfacing Mat'l: �..)Fireproofing ❑Paints Plaster U Textured Coatings Other:
Misc.Mat'l: U Cement Bd. U Cement Pipe Flooring Mat'l I.d Roofing Mat'l Other:
H. Asbestos/Demolition Project Categories: Notification Waiting Period NONREFUNDABLE
FEE
1. UResidential Dwelling Asbestos Removal Project Prior Notice $25
2. IJDemolition 10 Working Days $25
3. Uless than 10 linear feet or less than 11 square feet Prior Notice $25
4. U 10-259 linear feet or 11 - 159 square feet 10 Working Days $100
5. U260-999 linear feet or 160—4,999 square feet 10 Working Days $250
6. U 1,000-9,999 linear feet or 5,000-49,999 square feet 10 Working Days $500
7. ❑10,000+linear feet or 50,000+square feet 10 Working Days $1,000
8. LlAnnual Permit(Limited removal,additional permits,contact ORCAA) Prior to start of New Year $500
9. ❑Emergency Project Prior Notice $50
10. ❑Amendments(no fee for 1st and 2id amendment) Prior Notice $25
L I do hereby certify that the information contained in this notification,and supplemental data Payment received date:
described herein,is to the best of my knowledge accurate and complete. I shall not cause or allow Reviewed date:
any asbestos project or demolition activities to begin until the appropriate waiting period has Reviewed by:
elapsed. ,,,�p Permit Number:
✓ 6// t / \ Date faxed/mailed notification to applicant:
Signature GL / t/t DKate: t J For Compliance With Regulation 1,Section 14Asbestos
Print Name:k Pr-t- .rt,�h C5' SeCt l 4 p8 resenting: Agency Use Only
Rev.07/07/04
•
The'Olympic Region Clean Air Agency is the local air pollution authority for Clallam,•s 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 fee. 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 Contractor: Owner/CEO:
Mailing Address: in � �j'ti Phone:(60 ) (�I^ &(OQ
City: ci•tv.._Q t> State: it)1,0 I Zip: \l ) Fax: (760 ) S c>4 O Oa
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 AHERA 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 bum 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. Enter 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 plan,map of the structures,complete site address,type and
amount of asbestos material to be removed from each structure,AHERA asbestos survey,and work schedule.
Box H. Check appropriate project categories in boxes 1 through 8. Asbestos project fee does not include demolition project.
An additional $25.00 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 processing fee is required for all amendments* (1s` and 2nd
amendments have no fee requirement).
For technical assistance,or inquiries concerning notification and amendment status contact Dean T. Nguyen at(360)586-1044
J U N 3 2 2005
Rev.07/07/04
��.ggoN t^O JEFFERSON ( NTY
Or Ilik 1
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street-Port Townsend •Washington 98368
Q. � 360/379-4450 • 360/379-4451 Fax •
.kq�,�N www.co.jefferson.wa.us/commdevelopment 2005
t"s
... .vs.)
Master Permit Application ML O 5
A:
_ J
Project Description(include separate sheets as necessary): ___ _ ,
Tax Parcel O()` /� v xr
`� 1 ) Propel —1
Number: 9 6 Size: 11-00 c S,�,(acres/square feet)
Site Address and/or Directions to Pro '
Property Owner(s)oppf Record: q V
Telephone: .ti()^ -7t 2) -O,<C-6 Fa,c (Q,j- -ice ( '? ) email: '-Q•—
Mailing Address: f. y C.'O (Jie 6- `. ,z Gj1)p
Applicant/Agent(if different from owner): -
Telephone: (9 (� `� � s � e.z. c` .,
P ' G-— `7a.) f f Fax: ,- email: ``a
Mailing Address: r.(9 e.
'`ter L. .r �-r��. ei
What kin. •f Permit?(Check each box that applies)
0 Buil• . ❑Variance(Minor,Major or Reasonable Economic Use)
5 rr olition Permit 0 Conditional Use[C(a),C(d),or C]**
E jngle Family 0 Discretionary"D"or Unnamed Use Classification
Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
0 Manufactured Home 0 Boundary Line Adjustment )
0 Modular ❑ Short Plat**
❑Commercial* 0 Binding Site Plan**
0 Change of Use ❑ Long Plat**
❑Address 0 Road Approach 0 Planned Rural Residential Development(PRRDyAmendments**
❑ Propane ❑ Plat Vacation/Alteration*"
0 Allowed"Yes'Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate pp permit(s).
' �L�d-��, to act as my agent in matters relating to this application for
OWNER SIGNATURE Cfj .eL--,r- _ Date: G fit /o
S
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. My 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 pro access and right of entry to Jefferson County and its employees,representatives or agents for the sole
review and any red later inspections.Access andright of entryto this purpose of sstion
property shall be requested and shall occur only during regular business
hours. --
Signature: �.` _ Date: ( 7Jf//O
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"fake"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 ateurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. My individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if y are in compliance with the Jefferson County development code.The cant acknowledges
and non-trans for ringto and complying APPti that he,she or it holds individual
e plying with the ESA. The Applicant has read this disclaimer nd signs and dates it below.
Signature: .0 f i CV/W er
Date:
:\Pe rmitCcnter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT •
The signer of this statement reby ' that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming - ity of General Contractor for the proposed project.
Signature: r " Date: z/a-y t-
GENERAL/CONTRACTOR OR/MMANNUUFACTUREE-D HOME INSTALLER: PHHOONE: ��p �y FAX J U N 3 2 005
(
MAILING ADDRESS: S%r1 �T f2 / c:' L: / , 91,? I
CONTRACTOR'S LICENSE ���+1}v G C/ cit `C�WAiNS -
NUMBER: e)///7p/ iier ci C�/�LAt- NUMBER _- u.. _ ._,
ARCHITECT/ENGINEER: s / PHONE ( ) FAX:( )
MAILING ADDRESS: ' EMAIL -.:_ -
Pro hype: I Frame-Type: Bathrooms: I Shoreline: Type of Sewage
Disposal:
New Wood Existing: _ _ 0 Sewer
❑ Addition 0 Steel Proposed: _ _ Bank
0 unity System
❑ Alteration/Remodel 0 Concrete Total: Height eindividual System
0 Repair 0 Masonry - SEP Permit#
❑ Demolition ❑ Other. Bedrooms: I Water Supply:
Existing: — Setback: ❑ Pate well 0 Two Party
Type of Heat: Proposed: _ . _ Public
Total: _ 6 d ` Name of System..
-' t
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:
0 Underground Tank 0 Above ground Tank Size of Propane Tank:
❑ Heat Stove 0 Cook Stove 0 Woodstove ❑ Fireplace Insert 0 Hot Water Tank ❑ Pellet Stove 0 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 properly
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 " "` co •.:..�;c ,_;:- Y ,::!trI -,-':
Current I Proposed 5 ;�r" r,: w , .�,`
Main Floor ' • s t
Nl.) 'a 3 V 4 t it .
2 Floore. .'' :y t J �'_]
3n°Floor • �A .,� 'i :' :i i r
Mezzanine: Plan:Check$e =
.�•-t . -vl.� s ,'ice ' ." �"y t s,a .
Heated Basement o .' . .} -. ,r` Y ,'
k - v :,r t
Unheated Basement :' a �� ,
+ o x 'ft^.tT ] 2� 'y`'-:,.
Other Unheated •
� Y n T t -� to
ti,., a , ti r cry;sue
Garage/Carport /T �}' '., ��jj,, •x t` -''.:,:::�` 4s�'• r:�-�
Decks -,., . = _ .. < . ,t , :,
Other
ESTIMATED COST(REQUIRED) - ;- " . ih
•Fair market val .o•f all labor and materials foundation to finish i •-3 t, 7, i4�-` "'3
: .' . . . `.::iL :',,.- 4' ;;, -,..' p,1:-
G:\PrnnitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
1 I
)ical House Section
: 1/4" = 1'-0" o �'
Co
Cam CM •
ti
mama
s0 tit'v.g
,`
65 ft+
Th. .--- -__
rop ofmedU \-\
m bQhk . •
30 ft setback unless otherwise
nstructed by local code authority
erify
Existing dwelling / 1 Q�� ; 32'-0" /0" 1
I
I r 1 Existing dwelling to be demolished
I I
I I '0.Propose2:1 Dwelling_ Existing dwelling
1 ,,
+! I 1 +1 ,'.,
4- I I
O I I I 0
1D .11 1 1 I ,
Exist.septic tank I I F. I
field verifylocation T .J ''I; I Existing garage to be demolished
& separations to new I I
construction 1 rrl: ———— IT
^'
a u �.f
j o I c ! 1
� I _a
I V) i
VI
i
E I
I- I :::) .7
j En
i Property Description: •
I `.)
I u I Lot in Irondale AC Tracts
I d� NW 1/4 Section 7 T.29N.R.1EWM.
To exist' g drainfield o in Jefferson County>— ,3 Parcel No. 96270 L 096
�
e
d
>" 0 Address:
c
�a:' 140 Cleveland Street
Port Hadlock, WA 98339
Sch. • I 5it- • • n
z
Sco4e: 1" - 20ft
1
APPROVED
cs,
SITE PLAN
�' - 4 JUL 2 7 2005
JEF' O Y c_
DEPT.OF C9 D EL PM C
STGNATURFY Z
0
04
i
_ _ _ Stormwat s =
IY Required _
.r