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HomeMy WebLinkAboutBLD2006-00151 • 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 #: BLD06-00151 SITE ADDRESS: 32 VAN VALKENBURG PL e t Final Issu Date:Dae: 11/9/20006/6/20067 APPLICANT: MICHAEL VAN VALKENBURG PO BOX 306 PHONE: 425-3336874 CARNATION WA 980140306 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 921332013 Section: 33 Township: 29 N Range: 01 E PROJECT DESCRIPTION: NSFR W/A/G 250 GAL PROP TANK & RETAINING WALLS 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 not THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 11/9/2007 \F_BLD_Occupancy.rpt 10/29/19 0 • BUILDING PERMIT Jefferson County Department of Community p 621 Sheridan Street, Port Townsend, e WA 9838368 ent PERMIT# (360)379-4450 FAX (360)379-4451 SITE ADDRESS: BLD06_00151 32 VAN VALKENBURG PL Issue Date 06/6/2006 PORT LUDLOW Received Date 03/30/2006 APPLICANT: 98365 MICHAEL VAN VALKENBURG PO BOX 306 14,6-0 3'1 CARNATION WA 980140306 PHONE: 425-3336874 SUBDIVISION: PARCEL NUMBER: 921332013 29 N CONTRACTOR: Section: 33 Township: Block: Range: Lot: OWNER/BUILDER 01 E PHONE: NE: PROJECT DESCRIPTION: NSFR r CALL IN FOR THE REQUIRED I SECT SETBACKS: S THAT \ �, . APPLY TO YOUR PROJECT. L_.CQC UFFER: Footing: ,0_ ; Foundation: ,,.. to 9 0:„,E/ Stormwater FINAL A Underground proval: Under gPlumbing: Underground Insulation: 6 ", Shear Wall: Z /7 45 i Sheathing: Framing: • .�, '� Plumbing: n. ! /' - d o7or Propane Tank/Lines Insulation: p _IA., Sheetrock: Septic Sytem Final A 'D7 _ Road A Approval MUST be obtaine ni A ix) o� -,)�(-o Approach Final Approval: before final of structure can be attempted. upancy Approval: HEALTH DEPARTMENT AND PUBLIC WO CR> KS APPROVAL REQUIRED PRIOR TO FINAL INSPECT THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST g BUILDING INSPECTION HOT-LINE 379 F 55 CALL 24 E PE TO SCHEDULERLY RENEWEDS INSPECTION HOURS IN ADVANCE INSPECTIONS. Of LINE AVAILABLE 24 HOUO p.m. HOT SPECIAL CONDITIONS APPLY RS'4 DAY �jT it�cV l rn�� Fot,P SEE REVERS/ , in) � �N . 0147 BUILDING PERMIT APPLICATI* ML Revviewiew Type: e: I pe: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00151 Received Date: 3/30/2006 SITE ADDRESS: 32 VAN VALKENBURG PL PORT LUDLOW, 98365 OWNER: MICHAEL VAN VALKENBURG PHONE: 425-3336874 PO BOX 306 CARNATION WA 980140306 SUBDIVISION: Block: Lot: PARCEL NUMBER: 921332013 Section: 33 Township: 29 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NSFR Cam./ /-\/Li mil'j , Lkx H ILL Li TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,501 VALUATION 342,615.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: 1,062 HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: SHORELINE: CONST TYPE: DECK: 987 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 4 Total: 3 Total: 4 Routing Date"3 / O Type Amount Paid By: Date: Receipt: J\1Arroved/eat /E D Permit $2,354.55 LYK 03/30/06 80954 �.� V Plan Check $1,530.46 LYK 03/30/06 80954 JUN (o 2006 State Building Code $4.50 LYK 03/30/06 80954 Jefferson County Planning Potable Water Application $55.00 LYK 03/30/06 80954 & Building Department Total: $3,944.51 SPECIAL CONDITIONS FOR CAb BLD06-00151 • 1.) 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. 2.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat management plan dated February 7, 2006 and sign by WDFW and Mike Van Valkenburg. 3.) 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 4.) MANDATORY is intended to b illustrative of the types of water conservation measures. 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 for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC 173-160-106 173-160-171 (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. 5.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 6.) A flow meter shall be installed prior to final sign off of the building permit. 7.) 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. 8.) 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. • 9.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 10.) 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). 11.) The building height is not to exceed 35 feet. 12.) Minimum setback from Van Valkenburg Place and North Bayview Drive rights-of-ways shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum setback from shoreline top of bank shall be 30 feet. 13.) 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. 14.) 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. 15.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 16.) Residential developers and individual builders shall be required to preserve shoreline vegetation and reduce the associated risk of erosion during construction and any future activity which may impact the stability of the shoreline. 17.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. I:\F_B LD_Perm it_Buildng.rpt 10/29/1999 i • .ggON r °e, JEFFERSON COUNTY MAR 3 0 2006 DEPARTMENT OF COMMUNITY DEVELOPMENT ,...__..���� 621 Sheridan Street • Port Townsend • Washington 98368 � 360/379-4450 • 360/379-4451 Fax $IN http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# PROJECT/APPLICANT NAME: Pi/4 0-/.1I Ai)4'-t n.Lj Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate stormwater 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. tf ` .1 I,ti c) ;it .'L "/7�•L 7 S-: ,�,1 t'ti, q , A: I7� 4,t1�LAJr 1 r'o,v .O/1.1'('•V ; ' j, . ,leAir� J Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. MI/c- Wo Lo/S //)C6 GS S 7 ' i 4S T C. ` -c- T i9 t T L c -71te i 1- 5'i&L 1 2/Tmm'kty -7 4';,�' 7-- 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. o'TS OF ` 64-/►Ts 76t An GA Se „ L i%it A 4/7' 41 v dd i7)O.L/S 1-A)Q f ►'Lc) /1'�,),ci y TC 4. Describe the existing soils. Indicate soil type on the site map. SA-4/Q S Li 0 Art/ co 7- -nN L/e&7 5. Describe the existing site hydrology(i.e., drainage; behavior of water on the site—above, below, and on the ground). Indicate existing stormwater 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. A ;iv f A(C cc.J,v 70 r;- Sii9e f /20 'ei2i/ %l7 / _9,r _ _. 6. Describe any excess levels of noise generated by the proposed use or activ : A P P D 0 yL A1otie x c-,(/' f�i�'�/y _ S'/) a1 f _ Stormwater BMP's APR — 7 2006 I Required______- 1EFFE stormwater site plan template—rev-10/1/2003 RSON COUNTY 5 DEPT.OF COMMUNITY DEVELOPMENT SIGNATURE. • 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. A;e+I P , 4 rt. --f- liA i/e 7 r-yerzr I- s/i1C71•✓ , 4i' Ile'./ 70),e/ 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.). Permanent Stormwater Control Plan This portion of the Stormwater Site Plan consists of the selection and installation.of the appropriate stormwater control BMPs 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. g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30 in the Manual)or, if not, what types of stormwater 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. AAA Sc i%I./ f{ 6-Gr'A Po4I nib if/L-"Te S7S'7-'ell !I ALL STA / 01,1Wdie / •77fe S/S`7e4't _,-,c<.),t% sift,,i T s c o,'z,G- CCA i'tct/- CI /4) /9 /=, 2( 10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater 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.] ` 1 11. Describe the performance goals and standards applicable to the project. t.,)/ 12. Describe the flow control system. r,x . 4.) / 1 i stormwater site plan template—rev.10/1/2003 6 { k ' • • 13. De cribe the water quality system. btJet L DO ft)7' /(JO )(e-F Luc, r.,J, /:�1,!'., 7-7k �.J�37 ''.. Tt.'f7i74 jn T - -Te'2 j4,t..<H 9,;; fi- pe it 7) G.c;},i-7ei'Z, We C 'e`k - v /4 Re C C1 4'9 7? /1/M a? AA .c/i/iA 771 A /1 iJC c 7 -'c dC; r i AfJ rr r r/,1 r,e5, A 'e. J 14. Describe the conveyanc`system analysis and design. ) 1 MAR 3 0 TM ___J i 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.;4-.,,=E l;l (7-ril tle 1 '-orj 10-,z,,A1 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 4,2„,,p,... 17. Describe the proposed surfacing material. AJIP 18. Describe methods for restoration of the site. u0.e p LA v E Aj ii AVi`A/ f)75 c) (r2-A SS c g %j/;(��'�' /- 1 c-1 0 11 (-j-5/' e Jf�cc- t7- 45 /f)A7-1-1t ( L--- (7 CAN IT i s :-4-s' 7- A S P r.rL /7tezil e co,-- 1 ,-C c 1`) J'T [,v-r-5 t F /fAA-,' )1„ece 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. b ) '\-- 20. List here and include any special repo s or:-t ies conducted to prepare the Stormwater Site Plan. , A--- 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. r\ stormwater site plan template—rev.10/1/2003 7 • • CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMPs 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 Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential development. SECTION I—CONSTRUCTION SWPPP NARRATIVE 1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMPs 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). 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. tt-)R- 1-)-A tie S T Ke<4_ J+0,t- e i`i Is (24'7 4,47- r •l= ot-AA_ ,EXI r 1 jet/q 12(4 2. Establish Construction Access. &A e 4 /,4 V MLIh-ter',-0 7 1/C) (-0/j7)S L-O 7f C P f 1-K i .' 3 /;vOft itll 4At S w 7N /i /,t/C/9 -.(4 rz r S,44 w3 3. Control Flow Rates. /16,5`r. (7) F c-0/4-7-9 It (ram c OOw,t) f---t'C Atie ��T S Via, w' A-1--c- c VVe 12. 7 7) ife G1 rA)i 'T H tv�7-e,2 IL Ai 0 rF 4. Install Sediment Controls. i e A 12 e terse;,U STR-i+w uoe A n-e /MO Or',0. iT ;&i- 5. Stabilize Soils. � U / 7 L T o F �e//",fin l���i0! p�'S A-Pe c,A;1/9 711e t t-T 14 -ci* e ?Cr} Sil',/-11v. 6. Protect Slopes. ifl 9 ldc� j .S 6—ot`N 1J 42tr / ls ;T 1-1fire) S7j'pu) fl fLf►;►1_s l 7. Protect Drain Inlets. vi stormwater site plan template—rev.10/1/2003 8 • • J ii 12 Required Elements-Construction SWPPP(continued) 8. Stabilize Channels and Outlets. Lk)e [.1*Al OD NAV,`Nf H tip►t)"J AS t,AJt 9. Control Pollutants. IP,e A-D Cis ( /9-,v 9 C4 Aide 12 S`?-A-.v.0 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). (4-; ( -L r(cif)a,i'f7,./ (,Uc c);..L-C L2Q4 ( A)1 71frS I F t c',F4ej ; _ 11. Maintain Best Management Practices(BMPs). • 12. Manage the Project. u;f t-t i.ioAt`THd- 7 B'..,(d- i gel 7i1 3 f"/1/;09 Do 11Je r uotvor Ai ()pit-t't-'j74 4 IG bc• 7 LA)heA.) 6ovS rrt�,t•;�•.1 � 2. Adjacent Areas. a. Description of th adjacent areas tat may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roa ). �/2A/L 4Y/"icv i-f Eii � r�eJ7 y ,�-,� ,4L' C� pe4S`'tite f x.�f 7--n- /Cil/ CD.f]M4-6 n/1 T �./i) 7` i'.ST ir&b. ; j ii(,� /-01 Y £'O,4Y b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 y rds . e /rA � !Y �L-1`Te szei j(2 >2 q it-4/4 TS f,4-7c 1�'A/. 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. pi4- stormwater site plan template—rev 10✓1/2003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. kiti- 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,settleability,permeability,depth,texture,soil structure). 5Oi 1.4C L-ccKS EXQPCGeA./ 4 Uer\y S 1,41PZe. 5. Construction Phasing. a. Construction sequence ��--� /-/cry i /9-t i ei Awr Jy A P t c. d s7- //kti% 1 o «,e). Trcv, 1-jyz,y'7 'i/l/r . Y'fLff ii L.ti) /5t ,t- -1 Y 4. DI2Y _.Zit/ b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. 5O/'fr 77Me -.. '7 /,#i i v (/-iW/ it 5:_,,e,A t-�. /fy y .15 7 e ire - J AAAr9 6— cc J2 - II. Wet Season Construction Activities. a. Proposed wet season construction activities. 2 ii,,-LX V' b. Proposed wet season construction activities for environmentally sensitive areas. )7) /JC:::" . 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. tir;e C.:),1 V i1A iKeA!19-.1A f Z::t.,61;1-'0____ b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 40/..)_ 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. f b. Diversions. rp c. Waterways. �V �� d. Runoff/Stormwater Detention Calculations Ail l A stormwater site plan template—rev.10/1/2003 10 0 Stormwater Site Plan Changes If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan,the 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 included 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 affecte roperty. s • DOWNER OR AUTHORIZED REPRES WIVE.-SIGNATURE) DATE( ) s THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 1 l�, J o goo \ i.• �y t;iENY 12 stormwater site plan template—rev.10/1/2003 r i 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 assumingyy n �the 2' Z"\ sponsibility of the Ge eral Contractor for the proposed project. l / Signature: /'/w!'�- v�; .� %1,�;� Date: �l I Z ! 0�c- GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTORS LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: wi New R. Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank Height: ❑ Community System Alteration/Remodel ❑ Concrete Total: J [v-Individual System ❑ Repair ❑ Masonry �� r� SEP Permit# S fp OS-31-/(O Demolition ❑ Other: Bedrooms: Water Supply: Existing: _ _ — Setback: - Private well [7 Two Party Type of Heat: Proposed: �_ a Public LecTf1;L �'k'F'4 Total: 3 111;Vitx6t Name of System:USRe6-/4 i jh$T f,.N,p 3oft 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: CSC ❑ Heat Stove It Cook Stove [I Woodstove [IkFireplace Insert A Hot Water Tank ❑ Pellet Stove LI Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all 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 Current) Proposed For Office Use Only Amount Revision Main Floor Heated EH BId App Review: 2"0 Floor Heated y Consistency Review: i c, '2, Other Heated Base fee: 3 F 5 1"ILL-Q I I IQ\U7 _LjMezzanine Additional Section: Heated Basement �.5 .o�7'ob Plan Check fee: I ,`1 { Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: P� •� �, I L) . Garage/Carport SUBTOTAL (,)-1 Jt Decks ( 911/Rd Approach fee: ClIC5 FI i ,A16r _ _ xt5tn . Other E,J._ . --..-------TQ".T L: $ 1t t G�"� � t9C,PC-ti S )`,Z 5 fit P G D 1 , tipt Number: J \Vici b 1 b Cash/Check!tunas ESTIMATED COST(REQUIRED) t Date: �IO / .Fair market value of all labor and materials foun rnrs II 1 , ^� 5 t 0 '�f( Sf thltf Initials:' G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc ONo JEFFERSN COUNTY 44. t4 DEPARTMENT OF COMMUNITY DEVELOPMENT `44 621 Sheridan Street • Port Townsend•Washington 98368 360/379-4450 • 360/379-4451 Fax '` 2006 www.co.jefferson.wa.us/commdevelopment _0 SIN l� 1 Master Permit Application MLA: ��,,_ `' '1 Project Description(include separate sheets as necessary): 71.A.MMf Hv1-1e Siijt_c UACL /rod(/ )-±b,oe, Tax Parcel Number: 7 - 3 3-2- )c3 Qjj Property 1 /`fie S (a res/s �r .J Size: + � (acres/square feet) Site Address and/or Directions to Property: 3 2 Up&1 UM IKeNib:0, �r�itcC Property Owner(s)of Record: ill Ye U/'t 1V ]t e Ill 1.,l'lc Telephone: `IXy - 33.3 -(o(3 1y Fax: �g 3' 3- Cgcli email: Mailing Address: 3 9 tc ti E i-io hi pi-hc:e Applicant/Agent(if different from owner): I Telephone: Fax: email: Mailing Address: 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 C]** p'Single Family ❑ Discretionary"D"or Unnamed Use Classification [ Garage Attached/Detached 0 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)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment 0 Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment O 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: //__ �1 DESIGNATION OF AGENT I hereby designate VA`yr���2 i tLL r s to act as my agent in matters relating to this,application for permit(s). OWNER SIGNATURE±i07441. // Date: /26/ By signing this application form,the owner/agent attes 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. /�r,,�/ Signature: �� Date: h The action or actions Applicant will and rtake 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- transferable s on i ility,.i r adherin a d cgi1 plying with the ESA. The Applicant has read this disclaimer and signs an dates it below. Signature: Date: Z./4k G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc ,• (( i 0.00' e\- ui • rfl,"-s7:-`)'1 �N 1- 7-, zoA N0� X 1.-onv Z� rn •2. n I � --- Hi1 - 1 I i • . _1� I -„...„.--,.... a` e ----% • ti,): t,'",, Z. . 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