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HomeMy WebLinkAboutBLD2006-00187 0 • MLA06-00180 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00187 Received Date: 4/19/2006 SITE ADDRESS: 73 COMMERCIAL AVE PORT TOWNSEND, 98368 APPLICANT: SUZANNE YEISER PHONE: 1-949-515-1887 2916 IRVINE AVE NEWPORT BEACH CA 926603309 SUBDIVISION: JUNCTION CITY Block: 14 Lot: 5 &6 PARCEL NUMBER: 964501401 Section: 13 Township: 29 N Range: 02 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: VELLA TUDOR PHONE: 360-683-9522 CONSOLIDATED BUILDERS 251 OLD BLYN HWY PROJECT DESCRIPTION: NEW M/H - MODEL 4159 SER#0439-T TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW VALUATION MAKE: SKYLINE SETBACK: YEAR: 2006 LABOR & INDUSTRIES APPROVAL? SIZE: 44'X27' BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: ; lab , Type Amount Paid By: Date: Receipt: , A 144 at V E C Permit $163.00 LYK 04/19/06 81049 Potable Water Application $55.00 LYK 04/19/06 81049 MAY 10 2006 Total: $218.00 Jefferson County Planning Caul"-, & Building epartment . kr-" pct • • MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD06-00187 SITE ADDRESS: 73 COMMERCIAL AVE Received Date: 4/19/2006 PORT TOWNSEND, 98368 Issue Date: 5/16/2006 APPLICANT: SUZANNE YEISER 2916 IRVINE AVE NEWPORT BEACH CA 926603309 SUBDIVISION: JUNCTION CITY Block: 14 Lot: 5 &6 PARCEL#: 964501401 Section: 13 Township: 29 N Range: 02 W CONTRACTOR/ OWNER/BUILDER DEALER PHONE: PROJECT DESCRIPTION: NEW M/H - MODEL 4159 SER#0439-T MAKE: SKYLINE YEAR: 2006 SIZE: 44'X27' THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 5/16/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPL I YOUR PROJECT. Aetbacks/Foot g (CONTINUOUS FOOTING SLA: or PADS USED): �wWj' Cn 4.-.04. Stormwater FINAL Approval: Blocking/Plumbing: 9L-1 f Opp Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: e( C ,prf-e_F` 0,--)V L- 1 e"7 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 JACK WESTERMAN I Jefferson tillity Courthouse ASSESSOR PO Ilox 1'2ZT., fort Townsend. W.% 98368 (360) 385-9105 MOBILE HOME INFORMATION FORM APR 1 9 2006 OWNER'S NAME/MAILING ADDRESS: NAME: `\ �t.... �i.���-- ADDRESS c_k,c\. V*<.V`c-- t-Thtt.v PRONE NO. 33ce1 The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. 1)MOBILE HOME DATA: (A) MAKE 5-\-AI L- -� (B) MODEL `S- ` (C) YEAR 0L (D) LENGTH 44) (E) WIDTH �� (F)SERIAL # O 41:4 - l":7-' Z-1/3 S (G)YOUR PURCHASE PRICE (Do not include sales tax)4-40C\004=0. PURCHASE DATE 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE pA.cxt b%_.` � M- S ADDRESS .=\La\SC6\ ' -154 ' (B)WAS MOBILE HOME ASSESSED IN JFFERSONE CO LAST YEAR? Yes CNo If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No • (B)IF LOCATED IN MOBILE HOME PARK: NAME at, ADDRESS OF PARK Lot/Space # (C► IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: u. LOCATION ADDRESS REAL PROPERTY PARCEL #/D .CRIPTIO L SCD\ _ 44.) \WIN/kJ ure of applicant,THANK YOU FOR YOUR HELP! 6n n , r 056s1-e X JO COSSELL, Property Technician '',:.)' 19 96 02:29p Vella Tudor •681758O p.1 Kensington Park ,----1 .. , r Ot_il, v'', lri ■M ■ll►r N II t� ■rim•la - • ,a MIMI. iii p. i UTu.rrT---r I ra a�irlsairr • L1��I 1 �Tr� L�>•�wirnrnirr r-----rr-1 r+auprEso■ ``/ OPTION MASTER BATH 1 OPTION.UTWTY 1 kA9+/WYi_ ,�.MI atf IV ___111irni t 1{ I i I � �U wl: M� t E �+ "D{"rut BEDROOM 61r„ f w KITCNENIDI JI�S d ._r At No.2 ■11:11�'�Iu • . i7•4=____, QI 4ii�•■ t4� ■rruc�n rrr .,w. .�i l 3 .� II! I I �I / r - • ,._.,.r U N CAb1CFK l«awWt MASTER r. 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The application was reviewed by the Jefferson County Department of Community Development staff on May 9, 2006 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: landslide 2; SUSC aquifer recharge area; coastal SIPZ. 2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 5.) Marine shorelines and islands are susceptible to a condition that is known as seawater intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater suitable for public consumption without significant additional treatment and cost. Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater withdrawals (primarily through wells). The Washington Department of Ecology is the agency with statutory authority to regulate groundwater withdrawal for individual wells in Jefferson County. New development, redevelopment, and land use activities on islands and in close proximity to marine shorelines in particular should be developed in such a manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to the maximum extent possible by infiltrating stormwater runoff so that it recharges the aquifer. 6.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according to the County GIS map. There are voluntary and mandatory measures identified in the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23, 2002) that apply to well drilling proposals and building permit applications on existing lots of record. A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources within 1000 feet. 7.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 8.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 9.) Prior to and during approved construction activities, the perimeter of the landslide hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 10.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 11.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or any other prominent physical marking approved by the UDC Administrator. 12.) Critical Aquifer Recharge Areas•may require special protection measures to tigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 13.) 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. 14.) VOLUNTARY MEASURES OF COASTAL&AT RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 15.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 16.) MANDATORY MEASURES FOR COASTAL SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 17.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 18.) The applicant is proposing to create or add 1236 square feet of impervious surface and 1228 square feet of land disturbing activities. 19.) 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. 20.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(1)(b)(i). 21.) The revised site plan submitted on May 15, 2006 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated May 16, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 22.) This approval is for a manufacture home only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 23.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. • I 24.) 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). 25.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 26.) Minimum setback from Commercial Avenue right-of-way shall be 5 feet. Minimum side and rear yard setbacks shall be 5 feet per letter from Michelle Farfan dated 2/1/2002; 2002 General Correspondence file and parcel document in Permit Plan. 27.) 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. 28.) 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. 29.) The building height is not to exceed 35 feet. 30.) A minimum of two (2) on-site parking spaces shall be required for the manufactured home. 31.) An address of 73 Commerical Avenue, Port Townsend has been assigned to the parcel. Commercial Avenue is a county local access (C501009). 32.) The lot was created through the Junction City Subdivision on December 28, 1889 no AFN. The plat was amended on Marcy 5, 1891 under AFN 2703. 33.) A Declaration of Restrictive Covenant was recorded on September 12, 1997 under AFN 403703 to consolidate the lots for building and septic purposes only. 34.) The parcel has been designated as RR 1:20 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. RETURN ADDRESS ,J WASHIN6i0N STATE DEPARTMENT OF Manufactured Home �ELIMINATIONx���•�'�� �.l' LICENSING Application TITLE ELIMINATION ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine, imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 I Skyline 28 X 44 Serial#B891-0439-T AB © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE [AFFIXED REAL PROPERTY TAX PARCEL NUMBER ❑ REMOVED 964 501 401 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE 4-6 14 QUARTER/QUARTER SECTION Junction City © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 2 NAME OF REGISTERED OWNER 1 Suzanne Yeiser DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED OWNER Elizabeth Hackenbruch DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY 667 Braemar Terrace STATE ZIP CODE Fallbrook CA 92028 NAME OF LEGAL OWNER Same as registered owners DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY Title County/Office No.OR DEALERSHIP POSITION/AGENT/NOTARY AND: Dealer No.OR allotary Expiration Date TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION I certify that: Ig the manufactured home has been affixed to the real property as described. El a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME TYPED OR PRINTED) BLDG PERMIT OFFICE PHONE# BLDG PERMIT# �� �,t. f,�nttt:MA (� (or:)) 31 Cl-4a` 0 Fx 0t. -ODD 7 SIGN TU E/VP:ITIOi , , „n ) 3 DAT �c1 TD-420-729 R 6/06)W Pdge 1 of 2 /Jj 1.IlyVrniR_1RUr_ 1(1YJ.L 1 � (� IJ / MANUFACTURED HOME-FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 Skyline 28 X 44 Serial#B891-0439-T AB 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE Signature of Additional Legal Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY Title County/Office No.OR DEALERSHIP POSITION/AGENT/NOTARY AND: DealerNo.OR Notary Expiration Date D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) Lots 4,5, 6,and Block 14,Junction City, as per plat recorded in Volume 2 of Plats, page 103,records of Jefferson County,Washington. Situate in the County of Jefferson, State of Washington. 0 DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT.THE VEHICLE IS CLEAR OF ENCUMBRANCES ANY REQUIRED SALES TAX HAS BEEN COLLECTED. EXCEPT AS SHOWN. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORIZED SIGNATURE D ❑USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICE/VFS OPERATOR NUMBER SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE `ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX IMPORTANT: Once the application has been approved by the County Auditor/Vehicle Licensing Office, take your application form to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form, obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must return to a Vehicle Licensing office to file the Manufactured Home Application, paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this form for Title Elimination, Removal from Real Property or Transfer in Location, see form TD-420-730, Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation,please cal(360)902-3600 or TTY(360)664-8885. TD-420-729 (R/6/06)W Page 2 of 2 vomi IIII 6n . JEFFERSON COUNTY • t 4 DEPARTMENT OF COMMUNITY DEVELOPMENT I .. "' 621 Sheridan Street-Port Townsend•Washington 96368 4 • 360/379 445a • 360/379-4451 Fax APR 1 9 2006 4.1012 °- - . www.cojefferson.wa.us/cornmdeveloptne.nt Master Permit Application MLA: 6(o - 1 00 Project Revcription(includ arate sheets necessary): NQW ,V\ 1C Tax Parcel! Pnupewtt Number: yt.LSD i L nl sue: ►6_ t x t gc�t (acres/Square tom) • Site Address and/or Directions la Pro r: 1 �� ,�µ c Al ,d'`61 ��c , _ yu N. • Property O of Record ` -�^-.� ,----k�`� _Sa- • - Telephone. i -Rt.-V9-.e15-1.$c6, Fax. emit. Mailing Address 21RM .lvv i tic. kie_ / tthk 0 9-14" u.A£L-- CA CtZliz.at Applicant/'Ageat to different from owner): V e -I,,A i,(Z.--• Telephone' 1S - 1+Dt-1. • Faac(3(4) 1.01C1 - 2'42--• elnaiit:\f6,12.(_,,cf eA .Cc . Mailing Address-26 U l t,t Ir i . C . .I W CirK3 2.-- J Wbat kind of Permit?(C each box that applies) Viuilding ❑ Variance(Minor,Major or Reasonable Economic Use) 0 Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** 1 Li Single Family [7 Discretionary"D"or Unnamed Use Classification [] Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** t Mamdactured Htime ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** [] Commercial* ❑ Binding Site Plan** C] Change of Use ❑ Long Plat*" [] Address 1 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Ru merge ❑ Plat Vacation/Alteration** El Mewed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stdmmwaater Management [] Shoreline Management Substantial Development** ❑ Site Plan Approval,Advance Determinafi rr(SP ),* C] Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑ %irelesss Telecommunication.* C] Jefferson County Shoreline Master Program Amendment ❑ Forest Radices Act/Release of Six-Year Moratorium *May require a Pre—Application **Requires a Pre-Application Conference I Please identify any other local,state or federal permits required for this proposal, if known: / / tt DESIGNATION OF AGENT I hereby designate '1 Usa. 2' J l t e__ _to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Ag —- , , Date: ll j t j OW • By signing this application for owner/agent att: .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 o y 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 arty required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: i ,t,.1 f,,._ ....it:%4:v w'X. . Date: 0�� . 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-transfer ble respons' ility f.r adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: k.) i tj Date: 4 ! t U C;u: C:\Documents and Settings\mocha\Desktop\Master Permit Application 7-8-04.doc • • 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 begs uming the respongibility of the General Contractor for the proposed project. Signature: j4kCitS/ Date' APR 1 9 2006 GENERAL C@RRITR IroROR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) ` MAILING ADDRESS:: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHIIIL-LL/ENGi1NEEt PHONE ( ) FAX: MAILING ADDRESS:. EMAIL Project Type: Frame Type: Bathrooms: Sborerine: Type of Sewage Disposal ce/New i •'Wood Existing: 4,_42 1 0 Sevier 1 0 Addition Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel Concrete Total: -.I.. Height: 0 Individual System ❑ Repair Masonry SEP Permit# 0 Demolition Other. Bedrooms: water Supply: Existing: X .Q Setback: 0 Private well: 0 Two Party Type of Heat: Proposed: ❑ Public A.El• Total: Name of inn,. If this is a Commaercial Project you must answer the following: '` \Number of ParkingCurrent Proposed: , Number of AAelIa6 Padding Spaces: 1 Number of occupants(iinclia es owners,tenants,employees. etc) Current P►tlposed j IBC Vic. IBC Type of construction:_ Will you,have Food Service? Yes / No. suds is a Propane Tank and/or Appliance Installation permit,mark all items below that aptly: I Underground Tank I Above ground Tank Size of Propane Tank: I Heat Stove i Cook Stove I Woodstcve I Fireplace Insert I Hot Water Tank I Pellet Stove I Other Is this appliance being installed in a Manufactured I Mobile Home?, es+/' No When applying bra perms to instad a propane lark you must also sri7uynit a site plan showing all of the buildings,at property roes,,tank braear►and size,c stances from the propane tank to all property lines, buildings and septic system components,, incluchngr the reserve area Square Footage Cu Far aline Use Current { ' 2€ a v A. .rt (05 co VainFlair si Review 15310 • 24uFlOor ' Base fee: {Additional Section: canine. Plan.Cheri flee: R/ Heated Basement ' State Surcharge : )(`J'� Unheated Basement 0 Pot Water Review fee 90 AD Other I I/ cta�¢ rJln S� a i _, Garage/carport ! EXIST ►J P�9Po -97[0 9( !TOTAL: $ I _ °° Decks Receipt Number. 81�1g t Cash/Check Number: n�5t5g ESTIMATED COST(REQUIRED) Date: I,"1 �� 4Faiir welt off ail Ikr�nrr and/mrateirial&fommd&ottoRmish? b►lials: C C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc