HomeMy WebLinkAboutBLD2006-00012 •
CERTIFICATE OF OCCUPANCY
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451 (800) 831-2678
PERMIT #: BLD06-00012
SITE ADDRESS: 350 WASHINGTON LN Issue Date: 03/15/2006
PORT HADLOCK, 98339 Final Date: 6/13/2007
APPLICANT: TRACY GREENBERG PHONE: 360-385-2681
EDWARD BABAUTA
165A ARCADIA TERRACE
PORT TOWNSEND WA 98368
SUBDIVISION: IRONDALE AC TRACTS Block: Lot: 33+
PARCEL NUMBER: 962700039 Section: 12 Township: 29 N Range: 01 W
PROJECT DESCRIPTION: NSFR W/ATT GARAGE & ATTACHED SHED & UNDGRD 500G PROP TK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2003 EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes no
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 6/13/2007
11 Xtz-a (2/13/ 07
Building Official Signature �A Date
I:\F_BLD_Occupancy.rpt 10/29/19
*BUILDING PERMIT APPLICt'ION ML ReviewTy 010
Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00012 Received Date: 1/12/2006
SITE ADDRESS: 350 WASHINGTON LN
PORT HADLOCK, 98339
OWNER: TRACY GREENBERG PHONE: 360-385-2681
EDWARD BABAUTA
165A ARCADIA TERRACE
PORT TOWNSEND WA 98368 IRONDALE AC TRACTS
SUBDIVISION: Block: Lot: TR33J
PARCEL NUMBER: 962700039 Section: 12 Township: 29 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NSFR W/ATT GARAGE & ATTACHED SHED & UNDGRD 500G PROP
TK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,782"
VALUATION 218,650.00 ADD'L: HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER: 16
CONST TYPE: 5N GARAGE: 528 SHORELINE:
CONST TYPE: DECK: 162 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
SL VI ?D/oco
Type Amount Paid By: Date: Receipt: APPROVErPermit $1,660.15 LYK 01/12/06 78910
Plan Check $1,079.10 LYK 01/12/06 78910 MAR
State Building Code $4.50 LYK 01/12/06 78910 2006
Potable Water Application $55.00 LYK 01/12/06 78910 Jefferson County Planning
Total: $2,798.75 & Building Department
Lttok
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00012 Received Date 01/12/2006
SITE ADDRESS: 350 WASHINGTON LN
Issue Date 03/15/2006
PORT HADLOCK, 98339
APPLICANT: TRACY GREENBERG
EDWARD BABAUTA PHONE: 360-385-2681
165A ARCADIA TERRACE
PORT TOWNSEND WA 98368
SUBDIVISION: IRONDALE AC TRACTS
Block: Lot: TR33
PARCEL NUMBER: 962700039
Section: 12 Township: 29 N Range: 01 W
CONTRACTOR: OWNER/BUILDER
PHONE:
PROJECT DESCRIPTION: NSFR W/ATT GARAGE &ATTACHED SHED & UNDGRD 500G
PROP TK
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY T YOUR,PR9IJECT.
SETBACKS: ?et- rtA , Cj s oca- r� S1/ 0,
UFFER:
Footing: r'V.- -(A4
Foundation:1q S ('-Q6 j-
Stormwater FINAL Approval:
Underground Plumbing:
Underground su ation:
Shear Wall :
Sheathing: --(24.6-06
Framing: Pie iii/Z.61/4Jit/49t 4fi3/D1Z fr4
Plumbing: Z ' q/7-5/D6 60V-
Propane Tank/ Lines: 44` L' Lima 4,_ Q�iS/�IG
Insulation: g/,e s619` 4 ZS a, ak 47 �ON,f1ph /0/ 06
Sheetrock:_ l�- 4- v_ ��
111
Septic Sytem Final Approval MUST be obtained before final of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: t�> i j
HEALTH DEPARTMENT ND 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 A BLD06-00012
1.) 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.
2.) A Stormwater Site 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.
3.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
4.) 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).
5.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
6.) The building height is not to exceed 35 feet.
7.) 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.
8.) 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.
9.) Minimum setback from Wahington Lane right-of-way shall be 20 feet. Minimum side and
rear yard setbacks shall be 5 feet.
10.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
I:\F_BLD_Perm it_Buildng.rpt
10/29/1999
• a PERMIT # BlD
- 06 00 2
JEFFERSON COUNTY JFFFERSOLC LINTY OCD
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street•Port Townsend •Washington 98368 360/379-4450.360/3'9 45I Fax,
http://www.co jefferson.wa.us/commdevelopment/ =emu._%
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA: PROJECT/APPLICANT NAME: Babauta Residence
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 37,560 square foot parcel. The proposed improvement consists of the construction of a
single-family residence with attached garage for a 2,264 square foot total.
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
The site has a gently sloping landscape that has been logged, now with predominately first order
growth converting to second order new growth. Some third order growth exists in the form of mature
evergreen and deciduous trees.
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
The site is presented with predominately established first order growth converting to second order.
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 Sinclair series of moderately well drained soils that have a very slow
permeated layer at a depth of 20 to 40 inches.
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 moderately well drained. Permeability is moderately rapid above the cemented layer. Run
off is slow to medium, and the hazard of water erosion is slight to moderate. A perched water table is
on top of the cemented layer during the rainy season.
APPROVED
,S STORMWATER PLAN
Stormwa
Require JAN 3 p 2006
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SIGNATUR': 11 � ELO
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6. Describe any excess levels of noise generated by the proposed use or activity:
The proposal is for a single-family residence. The shop activity consists primarily of a cabinet
making capacity, which is conducted inside this insulated structure; hence, sound transmission is
minimized to almost nil.
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. Public rights-
of-way from historical plats contain primitive type roads that are privately maintained beyond the
Washington Street paved surface.
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.
10. If the project requires the use of storm water treatment facilities, describe the types of storm water
treatment facilities proposed for use on the site. Locate these facilities on the site plan and
differentiate proposed facilities from existing facilities. [This is normally for large" projects or
projects that involve the potential for dispersion of contaminants.]
No storm water treatment is necessary.
11. Describe the performance goals and standards applicable to the project.
All storm water is controlled so as to not create erosion or off-site migration.
JA N 1 2 2006
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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 such road ways to achieve the same effect. None will
migrate off-site.
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 500 square feet of driveway is to be created, using pit-run grave glacialbase course,
topped with 3/-inch and minus crushed river-run rock or crushed basaltic rock, which will amount to
approximately ten yards of material.
16. Proposed methods of placement and compaction consistent with the applicable standards on
International Building Code.
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 500 square feet of driveway is to be created, using pit-run glacial grave base course,
topped with 3/-inch and minus crushed river-run rock or crushed basaltic rock; which will amount to
approximately ten yards of material.
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.
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.
JAN 12 2006
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20. List here and include any special reports or studies conducted to prepare the Storm water Site Plan.
None known by the applicant.
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 SEP , Jefferson County
Potable Water Determination by PUD
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. Control Flow Rates.
BMP C121 "Mulching" will be implemented to filter any and all downstream water flow, and
thus stabilize the flow rate.
JAN 1 2 2006
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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 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
K. Maintain Best Management Practices(BMP's).
The owner is to supervise contractors to insure that BMP's are maintained to their respective
functional design.
JAN 1 2 rn
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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.
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
JA N 1 2 20n
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B. Wet Season Construction Activities.
1) Proposed wet season construction activities.
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.
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
OA N 1 2 2006 ;_
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• • •
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.
111-eL<A4 /o --.7 4 r-0 5
LANDOWNER SIGNATURE &DATE
JAN 12 2006
C:\Documents and Settings\Tom1My Documents\Business\Stonnwater Site Plan-Babauto.doc 10/25/2005
�ggON c�� JEFFERSON COUNTY 6
� DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend sh1nytorp- 8368
�� � 360/379-4450 • 360/379-4451 Fax
!iii
�yS, ,— G'SY www.co.jefferson.wa.us/con7mdevelopment
i
Master Permit Application MLA: l_; �, r
Project Description (include separate sheets as necessary):
R.J.1 (
1 d C c-t.FY\a.r\i R P S i ri C n C ( 1 GU/ a T la` (i)e s C c&r a 0 e
Tax Parcel Property
Number: `1 4v a. 7 C I
0 0 3 Size: 4
r ;� 7 F) C rc c� (acres/square feet)
Site Address and/or Directions to Property: 3 50 tvet 51„'n.3-v,. Lek„ e �e /
Property Owner(s)of Record: .--y- u c y _,r ,,,, h e
Telephone: e a(-_e) 3 3 5- a 4-.,? f Fax:
email: 1-)0, hcL;,.Ec. (cJCabieSf7,tr.rn
Mailing Address: I is ; A F rC e.ri,c_ --Fe r r ct c e Pc; ,} To -,S c.rti ci
Applicant/Agent(if different from owner):
Telephone: Fax:
email:
Mailing Address:
What kind of Permit?(Check each box that applies)
3d Building ❑ Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d), or C]**
%Single Famil ❑ Discretionary"D"or Unnamed Use Classification
)i1 Garage Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home 0 Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* Cl Binding Site Plan**
❑ Change of Use 0 Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
Propane CI Plat Vacation/Alteration**
I I lowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
I 1 Stormwater Management ❑ Shoreline Management Substantial Development**0 Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
f i Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
I] Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE
Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs, reasonable attorney'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 required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature:±_litek..1 D
�,L4. Date: /D -.7 0 5
The action or actions Applicant will undertake as a restllf of the issuanc
e 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-transferab respo s ty for dhering to nd complying with the ESA. The Applicant has read this disdaimer ang signs and dates it below.
Signature:
Date: ` U i - 2-ce—/ J l-
G:\PecmitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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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 dtcontractorrss and that
they will be assuming the res nsi ' the General Contractor for the proposed project. JAN l 1 2 2006
Signature: G t-
( 1 2 1�' Date: I/ - /,:r1- G'—
�'-�, —
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE:
FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER:
NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New .. .Wood Existing: v ❑ Sewer
• Addition ❑ Steel Proposed: — Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: X- . Height: Individual System .
SEP Permit# (-}1-t- � — 1 171
❑ Repairmo ❑ Masonry Bedrooms: Water Supply:
❑ Demolition ❑ Other: Existing: Setback: ' Private well ❑ Two Party
Type of Heat: Proposed: .; t.i Public
Total: 3 Name of System:
ei.O,cn. , i.>c: •l
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 appjm
X Underground Tank . Above ground Tank Size of Propane Tank:_5 OCR
[1 Heat Stove [[ Cook Stove I] Woodstove )(Fireplace Insert [1 Hot Water Tank CI Pellet Stove [I Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes C.91
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 I /14 S&P P VI-
-
Current Proposed Amount (cJ ' U
Main Floor _ Consistency Review:
' 7763 ‘)C\ a°. L"(p
I SS CO
2Nu Floor Base fee:
3ftl Floor v Additional Section:
Mezzanine: Plan Check fee: ®.i (1' V(°�,
Heated Basement State Surcharge fee: G��,.l�
Unheated Basement v Pot Water Review fee: tjl'\
Other Unheated 0
911/Rd Approach fee: 'RAlPO ,_ 6 1 G -I,S,) I e
Garage/Carport 5 a If 1 a`t z-N_Cl (. TOTAL: $ J 1 , 1 5 a ' 9. n J
Decks J 7 , to /6 Z 8 CT O i to r,Receipt Number: f 1 O
Other l t�D�� l Cash/Check Number: 8
L1D'74—
ESTIMATED-COST QU•REDD) Date: l I t)0
air rwricet value of all labor and mat 'al foundation to finish
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oP 1 ? , �! I--1 63(0 I ,o Initials: S =
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