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HomeMy WebLinkAboutBLD2006-00188 • • BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00188 Received Date 04/20/2006 SITE ADDRESS: 22 SHORECREST PL Issue Date 05/30/2006 PORT TOWNSEND, 98368 APPLICANT: PAUL KAASE PHONE: (360) 385-0221 2021 HILL ST PORT TOWNSEND WA 98368-7753 SUBDIVISION: KALA POINT#7 Block: Lot: 360 PARCEL NUMBER: 965000245 Section: 27 Township: 30 N Range: 01 W CONTRACTOR: PAUL KAASE CONSTRUCTION PHONE: (360)385-0221 2021 HILL ST PORT TOWNSEND WA 98368 360-385-0154 Contractor's License: PAULKC`061C5 Expires: 2/12/2008 PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARGE & DECK(S) (160 SQ FT) & COVERED PORCH (140 SQ FT) CALL IN FOR THE R U_I�E INSPECTIONS THAT APPLY TO YOUR PROJECT. SETBAC I�S: %��i� _ UFFER:f-'--A-7/,ceter Footing:'r4-7/s• o Foundation: 6 7/24/06P # 47T kef i-r FriS 04/4 Stormwater FINAL Approval: Underground Plumbing: Underground Insul tion: Shear Wall : `1 - 1 7'U Sheathing:A/Ai/5AA v1'44CM id v D c Lim-lob w�`c Qo17-64 Framing: ( 5i-(7-p6 F1_ (,ol 1i).Z7's--O� Plumbing: ?. --Z 5 -9l9 Propane Tank/ Lines: 1(3 Insulation: _`r))' ((-0(0 Sheetrock: i vl l()ep Septic Sytem Final Approval MUST be obtained before final of structure can be attempted. Road Approach Final Approval: Zoning Final Approval: ! Final/Occupancy Approval: W i° 4-J`6`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 SPECIAL CONDITIONS FOR CASE # BLD06-00188 1.) Critical Aquifer Recharge Areas may require special protection measures to mitigate 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. 2.) 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. 3.) 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. 4.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 5.) 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). 6.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 7.) Minimum setback from Shorecrest Place right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 8.) 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. 9.) 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. 10.) The building height is not to exceed 35 feet. 11.) A minimum of two (2) on-site parking spaces shall be provided for thw single family residence. I:\F_BLD_Permit_Buildng.rpt 10/29/1999 !UILDING PERMIT APPLICAT!N MRL Ty 182 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00188 Received Date: 4/20/2006 SITE ADDRESS: 22 SHORECREST PL PORT TOWNSEND, 98368 OWNER: PAUL KAASE PHONE: (360) 385-0221 2021 HILL ST PORT TOWNSEND WA 98368-7753 KALA POINT#7 SUBDIVISION: Block: Lot: 360 PARCEL NUMBER: 965000245 Section: 27 Township: 30 N Range: 01 W CONTRACTOR: PAUL KAASE CONSTRUCTION PHONE: (360)385-0221 2021 HILL ST PORT TOWNSEND WA 98368 Contractor's License PAULKC*061C5 Expires 04/25/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI NEW SFR W/ATTACHED GARGE & DECK(S) (160 SQ FT) & COVERED PORCH (140 SQ FT) TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,357 VALUATION 235,871.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO OCCUPANCY: R-3 UNHEATED: 360 # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: 528 SHORELINE: CONST TYPE: DECK: 300 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: KALA PT BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 3 Total: 3 Total: 3 Routing Date: i/c?i(/o� / i Type Amount Paid By: Date: Receipt: A 4P at V Et Permit $1,755.35 KAS 04/20/06 80977 �/ Plan Check $1,140.98 KAS 04/20/06 80977 MAY3o 2006 State Building Code $4.50 KAS 04/20/06 80977 Jefferson County Planning Potable Water Application $55.00 KAS 04/20/06 80977 &Building Department Total: $2,955.83 C1 eoIe'L -XgcJl�` 4'p JEFFERSON COUNTY,DEPARTMENT OF COMMUNITY DEVELOPMENT qoo' 0, ? HdV r 621 Sheridan Street • Port Townsend • Washington 98368 �O 360/379-4450 . 360/379-4451 Fax r" http://www.co.jefferson.wa.us/commdevelopment/ ';,1 STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# s.LP'V (p- IS t... PROJECT/APPLICANT NAME: Pii' 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. 1ila4 9.721JA1026 /-7)4 sbue.z .MR/1 y jit.. AL/u 6... /Joo s; Sf/ 71C; �D2.'�/a/!'//=/.Lip �/�il &/ L' �f CTG . Existing Conditions Summary �. 2. Describe the existing topography. Indicate contours on the site map. 1 F F F r r n _ ; r;, /LL ei0 /a cf0 rA/ G 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. -Cllegza L QPR, i,4 uiLVG/� i2�CS'i... �.4L.4 L /-i e/1 Ltri 3�72 e /7-14=2u f ,o P b.4101a2 a& 71 4. Describe the existing soils. Indicate soil type on the site map. ,L M/r14 'T /) Rd/L. 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. G'2o/&2rG / 2,u r 86504 %v /4W 4jJ rA sies o,e s7©gnw4-�, APPROVED 6. Describe any excess levels of noise generated by the proposed use or activity: STORM WATER PLAN AYt22/1/LL efe, ,,974, ii J /11r) ONLi MAY 1 1 2006 StorrowBter �o JEFFER CO TY��� Require DEPT.OF i TY EtO ME T S!GNATt, stormwater site plan template—rev.10/1/2003 5 • • 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. /VD Z7/A,VO�, S ,2 M S° 8Teg/' .PZ(OE5 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.).A-GC A0,%o/A,/! -C/T6S A2E 2r2-S'/11Ls//A-L .. . tub TT2e4111S U2 tv[57,64 j DS' 7/ 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 faciliti s. ST-0R14(V1�T (,[i/LG d L% rot (1- 0/S'/'4-2S' 6 /%p 3M/° l S:So... 4,7°Io or /,v//,[ (/e z477OAJ.., 412/6 PI re- f/AA../ DOowP,t T A/S'PL--ielVo ) f'E2 81.10 .S to .,. D/ki 1114- D/,?/°352/o Al (ofu fir .ahp 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.] WO f 264Tf/riUr !-Aetc./T,CS 11. Describe the performance goals and standards applicable to the project. /D Hg67— gGLG Ae/? L?/9P 5.3s 1'2: Describe the flow control system. OoCwaP2Jrg OT///ZL alocil,S . .. ,000/0674a0.1 ✓L(1/t/D ef O,UCc A!?/L4770,./ A.u4 ArZoio ,' )72!)L js DM" /ZE/ ijiI2Ei) t • stormwater site plan template—rev.10/1/2003 6 0 0 13. Describe the7 ater quality system. r-,.i, goo? o f >.J 4\ 14. Describe the onveyance system analysis and design. it, A 15. Describe the urce of fill material,physical characteristics of fill material,and deposition of excess material. Ai4 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. ti4 17. Describe the proposed surfacing material. (&4L /BOG''/� /24�F 4i/TN 3_S/ bt/a//JC r' fr c 18. Describe methods for restoration of the site. AGL /f//a7/!/L lJ 1i47/bAtl 6a1()26/% lv/LL C .P4000 4..tJ1J RL/0L/1/ui7 a 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. AJ A 20. List here and i clude any special reports or studies conducted to prepare the Stormwater Site Plan. Ai 44 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. ,tJQ hC alEtttfiJUI1 iiiiiiiiii oLiii stormwater site plan template—rev.10/1/2003 7 110 • 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. scc: f/TE di4AJ 2. Establish Construction Access. �0.u.7h9.ix T/on/ AGCL-f'S) /�.�S /3L G��J L- �T/J Q,L/�'/I L~Q UT/L/2/Ac1� A2/tJC-amc, >~PoT'pf2i 7 3. Control Flow Rates. Nor 2edaU/2e0 p v T/11/,j' ,PiTE 4. Install Sediment Controls. SM/t!s /7/L.6 I,/ //. fl i L CTFD 5. Stabilize Soils. /1!4-770 P20i/2 TTs,) /Al/T// rK/cT/AC ptrP!?74,7/e4... /-II,U/M4L oi,r702aAnicc >/Gc /9CCu2 6. Protect Slopes. AiiAJE 7. Protect Drain Inlets. /0piU/.r stormwater site plan template—rev.10/1/2003 a • • 12 Required Elements—Construction SWPPP(continued) r 8. Stabilize Channels and Outlets. 1•; AJOA/717 9. Control Pollutants. .$/'//t c Wit-- eL1s4-A 2 OP /'2bJ4AT/I ' 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). /3/4 P S )1/tt /26 -f/ nlT4-itle4► Ai 446 7/i4CS 12. Manage the Project. rr•- 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). J(ft9A,[r b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). IU/A 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. ASoMi st0560 stormwater site plan template—rev.10/1/2003 9 ! • b. Description of special requirements for working in or near environmentally sensitive areas. iU 4 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). l0/7/ 5. Construction Phasing. a. Construction sequence (.G t:A/ //rW, /ti`Yzr�S'T/Zu8Tv/2, /°o.U�Ti?OCr/OA1) ,9!.i°TI. s4�Tnpu t SiT4 fits->;7O/2A 1)0A/ 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. S'1T1: P,e�/t 6i-61Ng iAJ A4A(, 2004 ... 6rP6crco C ,°L&T/oAl /3c' /21 L©enG II. Wet Season Construction Activities. a. Proposed wet season construction activities. 1/AJ/S1i11AJl JAJTC2/D/Z b. Proposed wet season construction activities for environmentally sensitive areas. /1JDAIE 7. FinancialOwnership Responsibilities. a. Identify the prqperty owner responsible for the initiation of bonds and/or other financial securities. PAoz / 4A(1)E- b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. t '2Ob7/ ✓&Tet) ROAM g- /,f 1 su2,-nlF. . f 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. a. Sediment Ponds/Traps. / b. Diversions. /(1 1 c. Waterways. d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.10/1/2003 10 • • 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 owner f the affect d p perty. I GHQ a - 2 4-1 -c.4 (LANDOWNER OR AUT ORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: stormwater site plan template—rev.10/1/2003 12 • 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 INSTALLER: PHONE: FAX: PAo/ /)4/41e 069AJ T2oeT/oA/ (2k ) 3$s•ozvi (S‘o)VC: ois-4 MAILING ADDRESS: 7 z/ /I S'T. /: T, a),4,.. GJ,'3‘? EMAIL: CONTRACTORS LICENSE ' WAINS NUMBER: /O/t')/I/C- a /C 6r NUMBER ARCHITECT/ENGINEER: /�/1oL /i)44 O - PHONE ( ) FAX: ( ) /! MAILING ADDRESS: 5 I-1 A5- Jose v6- EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New X Wood Existing: * ❑ Sewer ❑ Addition o Steel Proposed: 2 z. Bank Height: ❑ Community System ❑ Alteration/Remodel 0 Concrete Total: Z rz nndividual System ❑ Repair 0 Masonry / P Permit# ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: _ Setback: 0 Private well 0 Two Pa Type of Heat: Proposed: --'1_ 0 Public Total: �L�G?2/G 13_ — ------------ N. me of System: /4G� o/AJr 077l. 7- If this is a Commercial Proiect 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: 1 ❑ Underground Tank X Above ground Tank Size of Propane Tank: /QQ c -4L, 0 Heat Stove cCook Stove 0 Woodstove X Fireplace Insert 0 Hot Water Tank ❑ Pellet Stove 0 Other Is this appliance being installed in a Manufactured/Mobile Home? Yes /(Nc When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all propel lines, tank location and size,distances from the propane tank to all property lines, buildings and septic system component including the reserve area. .. Square Footage Current Propoaed _, t�rrd111 n,. C). 4. ' , _ -. _. �z .I}E`-,.r. t}-1_1. . �,r.. Main Floor Heated Z S� 7-76; '-) EH Bld App Review: ��(� am{ f k;57. 2n4 Floor Heated i 4. ''; ',t Consistency Review: i2 •`_ WSJ CT Y .-• Y. Tcd' o- Other Heated �.�r�;;3�._".�;,� Base fee: "'i'=0-' x»' 55.35 Mezzanine �-',"". -" , Additional Section: , fitt Heated Basement }'_" , f) Plan Check fee: �.JS .I 3� X ) IItCO.. .GI :-r. 4, t Unheated Basement 3o • •7 State Surcharge fee: . $ i3O„ 5u Other Unheated `Pot Water Review fee: C DCt Garage/Carport $ i �� Ck, SUBTOTAL 3 a Decks ��O 911/Rd Approach fee: ,..- ---) Other ,`0UL2 cQ I'96'4'G/-1 ill u aZ --3 -�- T - TAL• $ ,:a0$. Receipt Number: /S b - Cash/Check Number: �APR 2 a 12006 ESTIMATED COST(REQUIRED) •� i. ,bade: .Fair market value of all labor and materials f �36 I__ 1/ 1 0�o ' E Jo ep Initials: J i .. -10r'P. yr G:\PermitCenter\FORMS\DRD FORMS\Meter Permit Application 12-30-05.doc orillN oO JEFFEF�IN COUNTY • IA DEPARTMENT OF-G-OMMUNtTY DEVELOPMENT 44 '4 621 Sheridan Street • Port Townsend ...Washington 98368 360/379-4450 • 360/379-4451 Fax www.coj efferson.wa.us//c�o�m Z gve Dment � C(f ° UUUUbb Master Permit Application ___1 MLA : IYALA()Co- Igo Project Description (include separate sheets as necessary): ,V Gt/ C0441-17N/GT/o&L, , .t- 1-„-4/9//. &G✓`LG/SIG Property Tax Parcel Number: %S 000 Z'/6' Size: Y Z 4Of2 (acres/square t Site Address and/or Directions to Property: __:,, `*/--'''ZZ,$)//026- e2e-c7 PL4C(- Property Owner(s)of Record: L 13i1,14- /44/15E. . 1.:, ' Telephone:,, _ 3,1, pie -/<' /34:-:/-r; email: t,-, Fax _ _ _ - Mailing Address: _ __ _r f..h,. -.. , , Applicant/Agent(if different from owner): 44'04 /M4S`E Telephone: O • 2 • ZZ / Fax: c o .3 d'S'". ,O/S�'` email: Mailing Address: 2 2 / /dL S - Q kill ._ f36 K What kind of Permit? (Check each box that applies) XBuilding 0 Variance (Minor, Major or Reasonable Economic Use) 0 Demolition Permit 0 Conditional Use [C(a), C(d),or C)"" %Single Family 0 Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached ❑ Special Use (Essential Public Facilities) 0 Manufactured Home 0 Boundary Line Adjustment ❑ Modular 0 Short Plat"" 0 Commercial* 0 Binding Site Plan" ❑ Change of Use 0 Long Plat'" 0 Address 0 Road Approach 0 Planned Rural Residential Development(PRRD)/Amendment: i(Propane 0 Plat Vacation/Alteration"" ❑ Allowed "Yes" Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions "" 0 Stormwater Management 0 Shoreline Management Substantial Development"" ❑ Site Plan Approval Advance Determination (SPAAD)" 0 Shoreline Management Variance 0 Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendmer 0 Wireless Telecommunication " 0 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 I hereby designate VA 4, kAA SC to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: 5/144/06 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 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 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 an 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 N ht of entry to Jefferson County and its employees, representatives or agents for the sole purpose of applicat review and any req I later inspecti s.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: aA L ( _c__,Q.,__\__,r____ Date: 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 p has been issued will not violate the SA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your actin even if you are in •Lr pliance with th Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non- transferable res.• Si.lity for adheri g to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. 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