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HomeMy WebLinkAboutBLD2005-00683 cUILDING PERMIT APPLICAkN MLA05-639 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00683 Received Date: 10/31/2005 SITE ADDRESS: 81 OAK RD PORT HADLOCK, 98339 OWNER: ROBERT E MATHESON PHONE: 206-230-0595 MARGARET E MATHESON 311 MASONIC HALL RD PORT HADLOCK WA 983399500 HILLERS WF TR INC TL SUBDIVISION: Block: Lot: 25-27 PARCEL NUMBER: 960300022 Section: 7 Township: 29 N Range: 01 E CONTRACTOR: CHISHOLM CONSTRUCTION PHONE: 360-280-2708 WAYNE CHISHOLM 1212 1ST ST PORT TOWNSEND WA 98368 Contractor's License CHISHC*972DJ Expires 03/11/2007 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOP NEW SFR ALSO A/G 120 GAL PROPANE TANK TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,375 VALUATION 129,402.00 ADD'L: 284 HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO OCCUPANCY: R-3 UNHEATED: #OF STORIES: 2 OCCUPANCY: OTHER: CONST TYPE: 5N SHORELINE: GARA CONST TYPE: DECKLE 655 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: ‘0\ 3tOS( Type Amount Paid By: Date: Receipt: A P MOUE Potable Water Application $53.00 SLE 10/31/05 77306 DEC as 2005 Plan Check $755.14 SLE 10/31/05 77306 Permit $1,161.75 SLE 10/31/05 77306 Jefferson County Planning State Building Code $4.50 SLE 10/31/05 77306 & Building Department Total: $1,974.39 C'&45 6v`s ( ci • • sir BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD05-00683 Received Date 10/31/2005 SITE ADDRESS: 81 OAK RD Issue Date 12/22/2005 PORT HADLOCK, 98339 APPLICANT: ALEXANDER AYZENBERG PHONE: JACLYN N AYZENBERG 3035 70TH AVE SE MERCER ISLAND WA 98040 SUBDIVISION: HILLERS WF TR INC TL Block: Lot: 25-27 PARCEL NUMBER: 960300022 Section: 7 Township: 29 N Range: 01 E CONTRACTOR: CHISHOLM CONSTRUCTION PHONE: 360-280-2708 WAYNE CHISHOLM 1212 1ST ST PORT TOWNSEND WA 98368 Contractor's License: CHISHC*972DJ Expires: 3/11/2007 PROJECT DESCRIPTION: NEW SFR ALSO A/G 120 GAL PROPANE TANK CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. SETBACKS: 1 //i/As4/` UFFER: -i ex ///3/04 /Y , Footing: "� �'� = /' / Ol�o Foundation: /,�(e //9 av Stormwater FINAL Approval: Underground Plumbing: Underground Insulation: Shear Wall : Sheathing: ?tor s1.iEA-Mix DY PER. PLANkieyO6 I `I- 6 Framing: i/ N .433 8--.6 Plumbing: ai eki- S-30 M. Propane Tank Lines: t44.4 S Se-pl, Insulation: AR. . AL 0.e LA74951 4A1-..4 -4r/,�.t1:4-b Ee7L'IX3D14 `1 Sheetr ock: ock: Septic Sytem Final Approval (If not on sewer): Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: k, 6(51/2_4(1,t&-� ,k'Z70 1 l 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 BLD05-00683 1.) The road approach permit (RAP05-00181) must be inspected and finalled by the Jefferson County Department of Public Works prior to the final inspection/certificate of occupancy of this residence. Contact the Department of Public Works at 360-385-9160 for the final road approach inspection. 2.) The development will be serviced by public water and a private well will not be utilized. If a well is required for potable water the applicant shall meet all of the Aquifer Recharge and SIPZ conditions. 3.) 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. 4.) 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. 5.) A Stormwater Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 6.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 7.) 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). 8.) Pre-existing legal lots of record less than one acre in size in Rural Residential districts are subject to the stormwater requirements in UDC Section 6.7 and must meet the "Area of Impervious Surface Coverage"to the maximum extent practicable as determined by the Administrator." Lot coverage is defined as amount of impervious surface, which includes rooftops, driveways, concrete, etc. 9.) The building height is not to exceed 35 feet. 10.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 11.) Lighting fixtures shall be designed and hooded to prevent the light source from being directly visible from outside the boundaries of the property. The intensity or brightness of all lighting, during construction and after project completion shall not adversely affect the use of surrounding properties or adjoining rights-of-way. 12.) The front setback is 20 feet from the edge of the right-of-way from Oak Road (south). The side setbacks are 5 feet from property lines (east&west). The rear setback is established from the Jefferson County Shoreline Management Master Program and is 30 feet from the Ordinary High Water Mark (wooden spool- north) for this low bank marine shoreline bluff. 13.) A minimum of two (2) on-site parking spaces is required for the single-family residence. I:\F_BLD_Permit_Buildng.rpt 10/29/1999 r APPROVED PERMU # BLD STORMWATER PLAN •MEDIIN"STORMWATER SITE PLAN SUBMITTAL T) 5 _ 0 6 8 3 JEFFERSON COUNTY DEC - 2 Z005 DEPARTMENT OF COMMUNITY DEVELOPMENT Y On 621 Sheridan Street•Pbrt Townsend•Washington 98368 360/379-445gE��� SOC 1 tt,, JEFFERSO CO TYt- p://www.cojefferson.wa.us/commdevelopmentt. VWPT.OF( :VE .0 ENT SIGNATURE: MLA: MLA95-00639 PROJECT/APPLICANT NAME: Matheson Residence PARCEL NO.: 960 300 022 LEGAL: Hillers WF Tracts Inc TL, Lots 25, 26, 27 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 a 21,480.84 square foot parcel. The proposed improvement consists of the construction of a single-family residence of 1,659 square feet, with 655 square foot deck, thus, 2,314 square foot total. Septic Tank and drainfield development will comprise 1,800 square feet, and driveway serving the development will comprise 2,200 square feet. Thus, the proposed impervious surface falls within the 2,000 to 4,999 square foot of impervious surface requirements under the Washington State Stormwater Management Manual for Western Washington as a "Medium"project Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. The site is a waterfront parcel[s] with essentially fiat landscape, with waterfront on the north side. The property slope totals an 8-foot elevation change on the west property line, and 3 feet on the east property line. These features extend laterally along the shoreline through adjacent land ownerships. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. The site is predominately first-order growth. Third-order growth exists in the form of mature evergreen and deciduous trees. 4. Describe the existing soils.Indicate soil type on the site map. The existing soils consist of the Hoypus [HvCJ series of nearly level to rolling soil on glacial terraces. The upper layer is generally sandy loam over gravelly sandy loam sub-base. 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 described as somewhat excessively well drained but holds water available for plants. Runoff is slow to medium, and the hazard of water erosion is slight to moderate. C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 1 6. Describe any excess levels of noise generated by the proposed use or activity: The proposal is for a single-family residence and only the typical accessory uses associated therewith. 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 have been determined for this site. 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 single-family residential uses, on large-lot land bases. Oak Road right-of-way is a paved [light bituminous treatment] road surface, which provides the traditional utility corridor. 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 flows to the surface grassed areas for transpo-evaporation, and natural infiltration. Road way surface grades will direct water to the downhill side of such roadways to achieve the same effect, where bio-filtration will take place of surface water. Intercept trench tight-lines are proposed on the south and east portion of the property, and seaward of the residence location 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 for this project. 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. C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 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. Road way surface grades will direct water to the downhill side of the driveway to achieve the same effect. None will migrate off-site. Intercept trench tight-lines are proposed on the south and east portion of the property, and seaward of the residence location 13. Describe the water quality system. None is proposed or required of this proposal. 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". 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 residence, and back-graded to form a slope away from the residence. Approximately 2,200 square feet of driveway is to be created, using pit-run glacial gravel base course, topped with 3/4-inch and minus crushed river-run rock or crushed basaltic rock, which will amount to approximately 30 yards of material, minimum. 16. Proposed methods of placement and compaction consistent with the applicable standards in the International Building Code,2003 Edition. Heavy machinery use will provide primary compaction. 17. Describe the proposed surfacing material. Yard area around the house will be seeded with grass and contain traditional landscaping plantings. Approximately 2,200 square feet of driveway is to be created, using pit-run glacial grave base course, topped with %-inch and minus crushed river-run rock or crushed basaltic rock, which will amount to approximately ten yards of material. The applicant may use the option of AC paving. 18. Describe methods for restoration of the site. None required, as site for residence does not require the removal of trees. The owner may choose to increase the number of existing trees with additional planting of same. C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 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. David R. Jensen, Professional Engineer, Site Plan dated September 19, 2005, approved by Jefferson County on November 09, 2005, depicts interceptor trench for surface water seaward of the proposed project, and on the south property line east of the proposed driveway, and the east property line. 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,Jefferson County Potable Water Determination by PUD Building Permit,Jefferson County, including addressing and road approach 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 only, and marking [flagging] equipment operation zones. B. Establish Construction Access. Via the existing roadway access point to the subject property, construction access will use BMP C105 "Stabilized construction entrance" to control vehicle and machinery tire displacement of on-site soils to any off-site roadway. Wash-down of vehicle tires on-site will further control such occurrence during wet days. C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 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 downstream 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 new vegetative growth is established G. Protect Drain Inlets. None exist either on or off the subject site. 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 foundation "crawl" 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 K. Maintain Best Management Practices(BMP's). The owner or owner representative is to supervise contractors to insure that BMP's are maintained to their respective functional design. C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 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. Coordination of utility work—i.e., same trench use included, coupled with 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. 3. Environmentally Sensitive Areas. A. Description of environmentally sensitive areas that are on or adjacent to the site. None known to applicant. B. Description of special requirements for working in or near environmentally sensitive areas. None required at this time. 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. The installation of Intercept trench tight-lines are proposed on the south and east portion of the property, and seaward of the residence location. 5. Construction Phasing. A. Construction sequence The applicant is to mark clearing limit area, establish construction access, foundation excavation, install proposed BMP's per plan, construct project, and then implement the permanent plan. B. Construction phasing(if proposed) Project to be started during the dryer period of the seasons, likely fall. 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 fall of 2005, and conclude by Spring of 2006 B. Wet Season Construction Activities. 1) Proposed wet season construction activities. C:\Documents and Settings\Tom\My Documents\Business\Stonnwater Site Plan-Matheson.doc 11/13/2005 None anticipated beyond attempting to keep materials dry. 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. 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, with back-up measures by the owner as part of owner's risk management for the project. 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 2. Site Plan. a. Legal description of subject property, b. North arrow, c. Indicate boundaries of existing vegetation(e.g.,tree lines,pasture areas,etc.). d. Identify and label areas of potential erosion problems, e. Identify FEMA base flood boundaries and Shoreline Management boundaries(if applicable), f. Show existing and proposed contours, g. Indicate drainage basins and direction of flow for individual drainage areas, h. Label final grade contours and identify developed condition drainage basins, i. Delineate areas that are to be cleared and graded, j. Show all cut and fill slopes indicating top and bottom of slope catch lines 3. Conveyance Systems. a. Designate locations for swales, interceptor trenches,or ditches, b. Show all temporary and permanent drainage pipes, ditches, or cut-off trenches required for erosion&sediment control, C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doc 11/13/2005 c. Provide minimum slope and cover for all temporary pipes or call out pipe inverts, d. Shows grades,dimensions,and direction of flow in all ditches,swales,culverts and pipes, e. Provide details for bypassing off-site runoff around disturbed areas, f. Indicate locations and outlets of any dewatering systems. 4. Location of Detention Best Management Practices(BMPs).Identify location of detention BMPs. 5. Erosion and Sediment Control Facilities. a. Show the locations of sediment trap(s),pond(s),pipes and structures, b. Dimension pond berm widths and inside and outside pond slopes, c. Indicate the trap/pond storage required and the depth, length,and width dimensions, d. Provide typical section views through pond and outlet structure, e. Provide typical details of gravel cone and standpipe,and/or other filtering devices, f. Detail stabilization techniques for outlet/inlet, g. Detail control/restrictor device location and details, h. Specify mulch and/or recommended cover of berms and slopes, i. Provide rock specifications and detail for rock check dam(s), if applicable, j. Specify spacing for rock check dams as required, k. Provide front and side sections of typical rock check dams. I. Indicate the locations and provide details and specifications for silt fabric, m. Locate the construction entrance and provide a detail. 6. Detailed Drawings. Any structural practices used that are not referenced in the Ecology Manual should be explained illustrated with detailed drawings. 7. Other Pollutant BMPs. Indicate on the site plan the locations of BMPs to be used for the control of pollutants other than sediment(e.g.,concrete wash water). 8. Monitoring Locations. Indicate on the site plan the water quality sampling locations to be used for monitoring water quality on the construction site. Sampling stations should be located upstream and downstream of the project site. Stormwater Site Plan Changes Changes or revisions to the originally approved Stormwater Site Plan: any proposed revisions shall be submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised drawings showing any structural changes, and any other supporting information that explains and supports the reason for the change. Final Corrected Plan Submittal If the project includes 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. (7;16/4; LANDOWNER SIGNATURE &DATE C:\Documents and Settings\Tom\My Documents\Business\Stormwater Site Plan-Matheson.doe 11/13/2005 m J ,- IL n w IY I- -7 111 (1 / _,..... O A. }�v o 0 cP (;)o poi`°0. W �Qo0. 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I* z j m .,, i(n PORT HADLOCK ; 4 v is g � � � AYZENBERG ::_. :-�µ-)' C Q a o ` rp Col JEFFERSON COUNTY 1" up o 3� PARCLE # 960300022 u 9 r• 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: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLED ". PHONE: FAX: CA ;shd/oN CGv1Sft()c/ ` L'i� ( ‘U ) i (Fd -?Ca� ( ) MAILING ADDRESS: /)..../, /S f S _ e j �L: fr � 9d'3G� CONTRACTORS LICENSE WAINS NUMBER: C// .5 // C 9 7)- LT NUMBER ARCHITECT/ENGINEER: 5-e,/,ece- ,40/," .. /b ,�.h t`5 s PHONE ( ) FAX:( ) MAILING ADDRESS: t/ EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: R New tl- Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: 2.. Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: 2— Height: ❑ Individual System CI Repair ❑ Masonry 4'c.,_) 2.SEP Permit# ©c-- T-I— D Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type f Hp at; Proposed: �_ $-Public /�i�.-`r W ./I Total: 5-. 30 f Name of System: If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current Proposed:_ Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: ❑ Underground Tank .III,Above ground Tank Size of Propane Tank: /5-6 fez 7 ti ❑ Heat Stove ❑ Cook Stove ID Woodstove ❑ Fireplace Insert 1 Hot Water Tank CI Pellet Stove Other e`,' 'YC Oil, . Is this appliance being installed in a Manufactured/Mobile Home? Yes /gil When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage For Office Use Only 2u Current ProposedAmount �r3D �(f; Main Floor l �1� 'Consistency Review: , ,� 3 Lip { , . 2�Floor icy/ 1sl 5 �5$ �e fee: 3 Floor Additional Section: Mezzanine: Plan Check fee: . i 53 14 Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: q 1• .CD Other Unheated 911/Rd ee r• Garage/Carport OTAL: $ R '" tt Decks ) 6 5,5_ ecei t Number: OCT 3 1 2005 t Other / _-�, f CashlCheck Number: . __._ ILI,OD ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish ( I js 21.9 Y-c co i a 3 � $� Initials: i l' G:\PerrmtCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc rik& oiv o JEFFEIN COUNTY' V DEPARTMENT OF COMMUNITY DEVELOPMENT 'w 621 Sheridan Street• Port To n gtoon 360/379-4450 • 360/379-445 ` L ° !": �: p www.co.jefferson.wa.us/com dew, �opifient " —''"'! �' . �`�BING� a I` OCT 3 i 2005 `" ,� - Master Permit Application ►= Ca- U 1 Project Description(include separate sheets as necessary): ._.,, - Tax Parcel Property Number: 5'6 0 ;3(70 oz)._ /7i //t'd'S Size: ,Z/ S1 r0.6' L/ (acres/square feet) p Site Address and/or Directions to Property: G/ vu.k /n 01, fi7s f/tud/ter' a,/9- Q Y3 Property Owner(s)of Record: ,'1)66,-er f /A,z-//i ei`SUi" Telephone: Z C 6 'i-- 30 D 5 c J Fax: email: Mailing Address: .30.35 lc) r-ti 4er.e ,S 1' A.e <‘C r k^ SSA -7d ` al i9. (''C?tom' Applicant/Agent(if different from owner): (�L/c.Yi"'e C h.l5,e/n c l't � i 5 4o'/.�i Cl3Nil`/ Telephone:360 .2-eo 170 ' Fax: / email: Mailing Address: /5_4 /s! Aci," � SA7,e4,4 S""C1( &/'n. 6,-/e 3 What kind of Permit?(Check each box that applies) l'Building ❑Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cl** Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** ❑ Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat*" ❑Address ❑ 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)* El 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: .� / DESIGNATION OF AGENT (%,`S�`A C�),,,S/ t r". I hereby designate 106, I 1(,A 6,' , 'i. / to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE/A. :71e%7!( 2,..5%'--4; Date: %t,'2 9 ;' t 3 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 provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any re led later ins 'ons.Access and right of entry to this property shall be requested and shall occur only during regular business hours. .- / Signature:Z'f i�f - _ '/7(CL � -/=c3 Z Date: / c/ 7 `' 6 , 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-transfespo ns ii for 9dhed to and complying with the ESA. The Applicant has read this disclaimer a signs and dates it below. Signature:x� �"!_ . 7Y�4- C`c Wit'/2 Date: ?. ;' G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc