HomeMy WebLinkAboutBLD2005-00674 MLA05-00629
UILDING PERMIT APPLICA1ON Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00674 Received Date: 10/25/2005
SITE ADDRESS: 207 SIERRA TRAIL
QUILCENE, 98376
OWNER: RON E SHEPHERD PHONE: 360-301-5331
MONIKA E SHEPHERD
207 SIERRA TRL
QUILCENE WA 98376-8616
SUBDIVISION: Block: Lot: 3+
PARCEL NUMBER: 601323002 Section: 32 Township: 26 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI` NEW MFH MODEL 4663L
ALSO A/G 250 GAL PROPANE TANK
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 60,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT: 450
SEWAGE DISPOSAL: CON
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date: to ( (ôs_
1:4
Type Amount Paid By: Date: Receipt: A P 1 ROVE
Manufactured Homes $157.00 KAS 10/25/05 77175
Potable Water Application $53.00 KAS 10/25/05 77175 JAN 1' 2006
Propane Tanks/Stoves $0.00 KAS 10/25/05 Jefferson County Planning
Total: $210.00 & Building Department
tOC
(3)-Q cye v
• •
MANUFACTURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD05-00674 Received Date: 10/25/2005
SITE ADDRESS: 207 SIERRA TRAIL Issue Date: 1/4/2006
QUILCENE, 98376
APPLICANT: RON E SHEPHERD
MONIKA E SHEPHERD
207 SIERRA TRL
QUILCENE WA 98376-8616
SUBDIVISION: Block: Lot:
PARCEL#: 601324001 Section: 32 Township: 26 N Range: 01 W
CONTRACTOR/ OWNER/BUILDER PHONE:
DEALER
INSTALLER: CELSO LAMAS WAINS1420 Expires: 2/28/200;
CHEHALIS WA 98532
PROJECT DESCRIPTION: NEW MFH MODEL 4663L
ALSO A/G 260 GAL PROPANE TANK
MAKE: SILVERCREST
YEAR: 2006
SIZE: 66 X 27
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 1/4/2007.
CALL IN FOR THE REQUIRED INSPECTIONS THATAPP --=, •UR PROJECT.
Setbacks/Footing (CONTINUOUS FOOTIN , SLAB • PAD USE : QG
Stormwater FINAL Approval:
Blocking/Plumbing: 40I 4-7;L_ _Dn:oN_. OK -3/7n.�, c
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps: fi 07
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 9:0C) a.m. -4:30 p.m.
HOT-LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY-SEE REVERSE
• •
SPECIAL CONDITIONS CASE # BLD05-00674
1.) PRIOR TO BUILDING PERMIT FINAL:
1. water sample that show compliant results for bacteria, chloride and nitrate must be
submitted.
2. The restrictive covenant that was recorded on 12/16/05 shall be re-recorded to indicate
that the applicant acknowledges that continuous treatment is required to comply with
potability parameters listed in WAC 246-290 Drinking Water Regulations.
2.) The property owner shall comply with submitted water conservation plan per application
on record with the water system approval.
1. The three bedroom home has a designed water system for 90 gallons per day at full
capacity in accordance with the water conservation plan.
2. no outside hose bibs are permitted to eliminate outside watering and maximize potable
water available
3. clothes washing machine shall be a model which maintains an average water use per
load of 10 gallons, in accordance with the water conservation plan.
3.) AN ENGINEERED STORMWATER PLAN HAS BEEN SUBMITTED TO 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 ENGINEER OF RECORD TO
ARRANGE A SCHEDULE TO INSPECT THE PROPERTY FOR PLAN COMPLIANCE. A
CERTIFICATE OF OCCUPANCY WILL NOT BE ISSUED UNTIL ORIGINAL
DOCUMENTATION FROM THE ENGINEER OF RECORD VERIFYING PLAN
COMPLIANCE HAS BEEN RECEIVED BY THE JEFFERSON COUNTY DEPARTMENT
OF COMMUNITY DEVELOPMENT. 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.
4.) Confirmation of the removal of all plumbing and kitchen facilities from the structure shall
be verified by the JC Building Department prior to final of the septic or residence.The
existing yurt located on the site will be converted to storage only. Conversion of this
structure to living quarters would require a conforming onsite sewage system to serve it.
5.) The application was reviewed by the Jefferson County Department of Community
Development staff on November 3, 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, the following ESAs were
confirmed to be present on the subject property: Shoreline Designation - Conservancy,
Wetlands (located at the shoreline), Seismic Hazard (along shoreline), Landslide Hazard
Areas - Slight, Moderate and High, Susceptible Aquifer Recharge Area (SUSC), Seawater
Instrusion Protection Zone (SIPZ).
6.) 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.
7.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
8.) 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.
•
9.) Among the native conifer species which may be used in buffers or for re-v getation
include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow(Saliz Lasiandra), and Scouler's Willow (Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry (Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray (Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sambucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry (Vaccinium Parvifolium).
10.) The owner is proposing to use a catchment system for their potable water supply. A well
will not be used. Consequently, staff did not require a hydrogeologic assessment be
submitted for this proposal.
11.) The development will using an alternative water source (rainwater catchment system) and
a well will not be utilized. In the future, if a well is required for potable water the applicant
shall notify the Jefferson County Department of Community Development and the
Jefferson County Environmental Health Department. The applicant shall meet all of the
Aquifer Recharge and High Risk SIPZ conditions as required in the Jefferson County
Code Article VI-E (Critical Aquifer Recharge Areas).
12.) 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.
13.) The parcel is located within a High Risk SIPZ (seawater intrusion protection zone)
according to the County GIS map. There are 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 High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses above 200 milligrams per liter(mg/L).
14.) A vegetative buffer of 50-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
15.) A geotechnical report dated eptember 17, 2001 prepared by NorthwesteTerritories,
Inc. was submitted in conjunction with this application. The report addressed the stability
of the geologic hazard area and concluded the site is suitable for the proposed residential
development, provided the recommendations in this report are incorporated into the
design. The report recommended a 50-foot minimum setback distance from the top of the
bluff to the proposed house.
Northwestern Territories, Inc. submitted a supplemental letter dated December 19, 2005
reviewing the relocation of the residence and the relocation of the reserve drainfield area.
The letter states, "With regards to the geotechnical report, as long as the recommended
50-foot buffer is maintained from the top of the buff to the home and the reserve drainfield,
and that the drainfield is not located between the home and the bluff, the revised locations
are acceptable and are consistent with the recommendations of the geotechnical report."
16.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated.
Should buffer disturbance occur during construction, the Unified Development Code
(UDC)Administrator shall require replanting with native vegetation. No alterations shall be
made to the Landslide Hazard Area or its associated buffer without prior authorization by
the UDC Administrator.
17.) Prior to and during approved construction activities, the perimeter of the landslide hazard
area buffer shall be marked with a temporary sign. The sign shall be placed in such a
manner that it can be directly observed from the construction area. The sign shall contain
the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter
Existing Vegetation."
18.) All construction activities shall not encroach upon the buffer. This includes the storage or
preparation of materials.
19.) The applicant shall permanently separate the boundary of the Landslide Hazard Area
Buffer from the remainder of the subject property through installing logs, trees, a hedge
row, or any other prominent physical marking approved by the UDC Administrator.
20.) 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.
21.) MANDATORY MEASURES OF HIGH 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.
22.) MANDATORY MEASURES FOR HIGH RISK 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 requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106
for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e) of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
23.) 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.
24.) The applicant is proposing to create or add 1,980 square feet of impervious surface and
5,400 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson
County Unified Development Code requires the project applicant submit a stormwater plan
meeting Minimum Requirements#1 through#5 of the Department of Ecology Stormwater
Management Manual for Western Washington. The stormwater plan shall address
measures to control stormwater, erosion and sediment during construction and shall
address permanent measures to stabilize soil exposed during construction, and in the
design and operation of stormwater and drainage control systems.
25.) 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).
26.) The revised site plan as submitted on December 7, 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 January 3, 2006 shall be resubmitted for review and approval by
Jefferson County Department of Community Development.
27.) This approval is for a manufactured home 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.
28.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
29.) 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).
30.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
31.) The building height is not to exceed 35 feet.
32.) 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.
33.) 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.
Ill
•
34.) Setback from Sierra Trail right-of-way is no less than 20 ft., side setbacks are no less than
5 ft. The geotechnical report submitted requires a 50 ft. buffer from the top of the bluff to
the proposed residence. If an environmentally sensitive area (ESA) is present, then the
more restrictive setback shall apply.
35.) This is a legal conforming parcel designated as Rural Residential 1:5 under the Jefferson
County Comprehensive Plan Land Use Map effective August 28, 1998.
36.) A septic permit(SEP05-00305)was approved December 22, 2005 for a capacity of 360
gallons per day.
37.) Sierra Trail (P543) is a private local access road. A road approach is not required and an
address of 207 Sierra Trail has been assigned to the parcel.
38.) A minimum of two (2) on-site parking spaces is required for the single-family residence.
39.) All recommendations made in the geotechnical report dated September 17, 2001 and the
supplemental letter dated December 19, 2005 prepared by Northwestern Territories, Inc.
shall be followed.
JACK WESTERMAN. Jefferso unty Courthouse
ASSESSOR PO Box 1950, Port Townsend.WA 983611
(360) 305-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS: ' r---- _�
NAME: P60/0// /M'23 fr/MI/ ,9 $,&P//ERo
ADDRESS: Zd? 5ie rra_ -[i'4tL Qt,<<c.ede / oda . 9S5?G.
' 252�
PHONE NO. 04,05 36/ - b 33/ 1
LnrrT ( k
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1
1)MOBILE HOME DATA:
(A)MAKE S/G f/.iees,e�.�/ (B)MODEL (� -4- (C)YEAR ''')e' :'
(D)LENGTH (E)WIDTH 2 ? (F)SERIAL# 7..B
4G)YOUR PURCHASE PRICE(Do not inc ade sales tax) cat', e'4O PURCHASE DATE /?.��
2)PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE
ADDRESS
(B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes (o /
If Yes, Previous address of mobile. 1
If No,What County was Mobile assessed in last year.
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes (No
(B)IF LOCATED IN MOBILE HOME PARK:
NAME A.ADDRESS OF PARK Lot/Space #
(C) IF NOT LOCATED NAME OF LAND OWNER: HONOW/Mg '1' '&�,t94 ��,#�
' LOCATION ADDRESS 20 / S/� 'C'i/ ' �C*/./ dPL c d1 9 8574,
REAL PROPERTY PARCEL#/DESCRIPTION 6Dl 5z3 oO Z &0I 3Zy 00/
2AAtkiS
Signature of applicant
THANK YOU FOR YOUR HELP!
dCt3A SS-e SI
OSSELL, Property Technician
6 OWNER BUILDER STATEMENT ill
The signer of 's statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
theywill be u ingnsibili of the„eral Contractor for the proposed project.
1
Signature: 4 -_ ? 1 1 Date: _ tO/t'0(i 5
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
i_ e-- / ,r ( )
MAILING ADDRESS: / .?.- ; " EMAIL:
CONTRACTOR'S LICENSE %s."S`,,,; WAINS �/
NUMBER: NUMBER/ rx' .) `� Z( (C��
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
--I -New IN. Wood Existing: V ❑ Sewer
0 Addition ❑ Steel Proposed: Bank ❑ Community System
O Alteration/Remodel ❑ Concrete Total: i' Heig_ht:,
r' ✓Individual System
O Repair ❑ Masonry q )O SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: 3 Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: , r ❑ Public
F 4.- Total: 3 Name of System:ALTe(M&1We
C, tzt.rw MT SrbTGw`
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: 2.5 sic'.3h' �L c'
❑ Heat Stove X Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank X Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home?Cr, / 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 1
Current Proposed Amount
Main Floor Consistency Review:
: :, 419, do
214"Floor Base fee: I
3rd Floor t, t
1 I.
ettion: _
li l V-V i' 1 I,..•,\
Mezzanine: ' ' " --PtaTrChelj fee:
tl1 Ii I
Heated Basement !I I lei 2 5 awe Stkct`arge fee:
Unheated Basement Pot Water Review fee: r�
GCF7. CI !EFFE ' aT1'``JR'TY `d CJ
Other Unheated _ L .I . ' t1<CRd;AJpproach fee:
Garage/Carport
TOTAL: $ C El-y
Decks Receipt Number: " 1
Other Cash/Check Number:.
ESTIMATED COST(REQUIRED) Date: f�
•Fair market value of all labor and materials foundation to finish l L J-r
05
Initials: K��
V
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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4i V JEFFERSO UNTY filirhi
l f ��rDEPARTMENT OF COMMUNITY DEVELOPMENT f t Lnr)
621 Sheridan Street• Port Townsend •Washington 98368 ' :-0 i, I,
.' 360/379-4450 • 360/379-4451 Fax !I 1 i in 25
2005 I I ,
0 www.co.jefferson.wa.us/commdevelopment
1`S4INGrS ,
Master Permit Application „r' �'_r ", ,
�- �Project Description(include separate sheets as necessary): � �
6 Vic`/ /T , 'Pig' r 6f 1/t'fr '2x'c'.> He/t - 4,A, fitev� i•
Tax Parcel Property
Number: 60/ .32-3 Op Z. - 6,0( qzq 0 01 Size: /1 AL/'es (acres/square feet)
Site Address and/or Directions to Property: Z 0 7 Ste AT G� (r c..t C_ 0ti ..c et.. e , Oa- q S 31G.
Property Ow er(s)of Record: I�e�1 4 f\&d nl •iCc. gik. �it.et d
Telephone: 0too) 30 / - 5 331 Fax: email: PnN r16Ni Ka® direc.t.,ay-ca
Mailing Address: Zo7 5fePlek'x"ptiii- DucLce"te 1 Wa• 9g316
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Al-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)**
-0-Manufactured Home Li Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address [I Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
FJ'Propane ❑ Plat Vacation/Alteration**
f_l 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
El Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
LI 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 act made Wle owner/agent with respect to this application packet
may result in this permit being null and void. �_ +I�
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and a required later inspect. .A• - and right of entry to this property shall be requested and shall occur only during regular business
hours. o� y if
Signature: t .Laik (� • t Date: /0/N IB S
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-tra rable responsibility for a• ering t• . • complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ouk 4...0 s• C_, • rt Date: /Q /to%
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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