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HomeMy WebLinkAboutBLD2006-00198 PERMIT APPLICATN ML viewTy 193 PUILDING Review Type: I Jefferson County Department o' Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00198 Received Date: 4/24/2006 SITE ADDRESS: 1031 DUCKABUSH RD BRINNON, 98320 OWNER: WILLIAM J ZELEN PHONE: 360-796-3441 PAMELA ZELEN 1031 DUCKABUSH RD BRINNON WA 983209622 SUBDIVISION: Block: Lot: PARCEL NUMBER: 502171010 Section: 17 Township: 25 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr NSFR W/ATT GARAGE, DECKS & RAN t,t0 a1rt-tin m- TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 913 VALUATION 258,967.00 ADD'L: 1,453 HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: PRO OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: 750 CONST TYPE: 5N GARAGE: 440 SHORELINE: CONST TYPE: DECK: 800 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 2WELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 3 Total: 3 Total: 3-- Ror`d a Type Amount Paid By: Date: Receipt: APPRIOVED Permit $1,884.15 LYK 04/24/06 81118 Plan Check $1,224.70 LYK 04/24/06 81118 MAY IS 2006 State Building Code $4.50 LYK 04/24/06 81118 Jefferson County Planning Potable Water Application $55.00 LYK 04/24/06 81118 & Building Department Total: $3,168.35 • • BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00198 Received Date 04/24/2006 SITE ADDRESS: 1031 DUCKABUSH RD Issue Date 05/19/2006 BRINNON, 98320 APPLICANT: WILLIAM J ZELEN PHONE: 360-796-3441 PAMELA ZELEN 1031 DUCKABUSH RD BRINNON WA 983209622 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 502171010 Section: 17 Township: 25 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: PROJECT DESCRIPTION: NSFR W/ATT GARAGE, DECKS & A/G 250 GAL PROP TANK CALL IN FOR THE QUIRED INSPECTIONS TH T A PLY TO YOUR PROJECT. SETBACKS: 5�2y4-i4 m, � '7 14 via UFFER: O Ø/ "G /p j' '' fD/rf/CGS ak. '/5/07 p" Foundation. -1 f Stormwater FINAL Approval: Underground Plumbing: i,/4 Underground Insulation: iu/A Shear Wall : I —1).—Ct t t , Sheathing: Framing: u/F ciat411,4 OX SP7/04P O/S 4/kpl (ij Plumbing: DK 4/4/a Propane Tank/ Lines: ,JJi4 Insulation: li L OK 4/4/4774421Lx;45 (AIL, q-1kr)" t ) (71_4 c SheetrocC Septic Sytem Final Approval MUST be obtaine before final of structure can be attempted. Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval 7/ I/77 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 # BLD06-00198 • 1.) Approval from the health department is contingent upon the existing mobil home permitted under BLD01-176 being removed from the property prior to final approval. 2.) 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. 3.) 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. 4.) 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." 5.) All construction activities shall not encroach upon the landslide hazard area buffer or wetland buffer. This includes the storage or preparation of materials. 6.) 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. 7.) A setback of 150-feet, measured perpendicularly from the wetland edge, shall be permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the wetland or its buffer is allowed. 8.) Wetland buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall contain the following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation." 9.) A permanent physical separation along the upland boundary of the wetland buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 10.) 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. 11.) 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. 12.) 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. 13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. • 14.) 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). 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.) Minimum setback from Duckabush Road right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. Minimum setback from edge of wetland shall be 150 feet per wetland delineation dated August 11, 2002 prepared by Applied Environmental Services, Inc. 17.) 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. 18.) 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. 19.) The building height is not to exceed 35 feet. 20.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. I:\F_BLD_Permit_Buildngspt 10/29/1999 71Pg6FIPA -. r".-7). ,' - a, , , ...,,, „„,,, .. ,_‘,. .,.., Am • A.D ' APR 2 4 2006 A • og 0, j 1 3/4" 1 3/4"-1 1 7" 1 — 1 1 8'-or 1 c. 8'-6' 12-q° 13'-5"-- MIMI 6" r 7050 m I I ,.. ,...._ _7i7"---7----iii-----r--'41""'—usa mmmmm um'''' "-ii). , 0 - •-• )'\_ 111111111 �I�,m s 1 = p „ m • n I q \ X 1 l Lh: —Ie 11r1 - --9 \ 3 r` nX 1 ( ( S . rg l �-I 0 I/. i fir D j ,\ ,�.� r �u • -0 +� \ 1 / 4.7 'Q i T. •I I 1 „ I • • i , 11 / _ • , bi ;-;4. - 1, L. l! f - . 1 i 1 1 I ./ . -11 q11111 • p ♦._ \�. = W IAL,-•,� {III, �" 14" .I• \° •�, � , I i ��c)] j /" T I gip` W ° D ° `-' z D 1 ° Xs =T' 1— 19.I° \ 15' m '1" 1 4 3:12 c REFRIG^ �N _pG`��w-'.' a� U Ir 36'CQ. I t CIb 0 4 •A! 1 Ali_ .\ ,N ' P P 1 B �' != $6 , X � \Sly '° ��* �� I'� ` ..,, ,,,•„ , tv-m_.,___..la ! pnit4 r T. 1 ,,i. .11r q 4 i <\ T w C ri 1 ).,! 'k --I a). \ ' G\ ,..,.°L ,,, 7.. 11 11 Its „ - - .----______----_1 ,,..... \.,. rn qs_u V s WORK® `1 l 9_OVERHEAD DOOR �==�1 49'OVERFIEAD DOOR ♦ •i�•••� 30 • :C ♦♦��♦••{♦ ♦ ♦ { 1 I 41'-II" ®D /NA,. a - m =L5 —"rr '-1 1/ g g g „.- .11 \sip\, iz,,,,,,' riiiiiiE 'g-4 . .! @ i ii2 011 M i 1 t"i 11 CO. 111°' 1/111' i ij Eg g 0 --, m , X,.... § t t'i V Llg ;1 - tr. ' , to g 80 p a i m u) _ $ — - 1'11-s 1 1('-1'= .. 1. I I'•b' ' " 12=`t (-8; _. 5'_4ot -r -D ` _i_ E _ Zai50 Z&Sp CHA'NEY I ❑ irk I.:,.,� � w 1 , . . 0 f.,. FF 4"NEI d. 6. t co al 9 c-i 3> zili �N f0` .__*:_____...44 rn iA 02 i 6, .fi Ippppb r l 1 J„%�i I 3'11 V2h t c i I",. t I I I . q b X \i m w . . C3 r 8aA. % ` IX-re I /0'-4 V2' as I t �' - sLOPEv b. cLGI P II ' Pir 1.> z 1 4. ,,. ' ❑ ID LINEN O \ •I• • 6 \ v �.n��m0' to S �� :,,,, 1 :_rs, u W,i to i� , i 1 j —')71 r61 I '::1' g 26 _ A J• =rFm (r NE' - - 10(EEWALL sa� �\ \ /� y t .ti71 - 7 N N I 11 4 R£3 \ ,L.ti / �rQhj Y rC oW SLOPED CLG -j, ) S .. m -� S'CLG ('� r S q ~ N I SLOPED LLG' �+- 1 f ` ' m w» .': cP.N V+T ' I t 1\ iw $ NNj ra I l'ati , , qf . 1. ,,,. ,,, / . _____[.___, \ �r Aii%� LI r '.. . ..". — ;'. 3°9°,TPoPLE. 20'40" 9'-3 IR" 9.-3 V2" r 19'•T° r 39'-5" r • 0 ,_. _. _ r te c°� JEFFERSON ' APR 2 4 2oor� COUNTY _ Y it ►�� DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 .��...iO 360/379-4450 • 360/379-4451 Fax a` http://www.co.jefferson.wa.us/commdevelopmenV STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# I Ct PROJECT/APPLICANT NAME: `t 1;11)tik;rn Pa Vie_i,i 7 4I -£y i 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. «ix.�.r \,/v v-v1 • w� o_.k i a.- - I.e ,-. (:{;r I 1 i(1„id Si cte .ti . l) Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. r 1 c._ ,....: iI =--1c..i.--. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. �...�rC&'- c2)) c7a...-t. t�--L / ,'-%f ,e.-Ly-e L r V:'Li.. . ..) �Slle 'L i •I�1 '-�._.` . . ,) d 4. Describe the existing soils. Indicate soil type on the site map. --.-re-.i.- , k..C .1 ) (-5 c)k rv',,i,c L: v-.{•.. c lnk,:S 1 c--:Z'>c..k- C r0..1a\ I +'� • 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. .r, , k L;-,c 4;.- 0-1-ca1 A- . - NiCr 6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED V ED 3.../ f STORMWATER PLAN _ P i JEFF U stormwater site plan template-rev.10/1/2003 St0'ft1114 DE PT.On DI'V OP ,NIT`t 5 Begun d SIGNATURE 1 C� M lllh • • 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. o`.itk) ')(l_ i t ("' ji �rc2 LC��� . 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.). jvi 1 tk.a A rJ i U LA,C,c .6 f.0 :�i� ..t v t b.c J p r O UY tf tL'Y�l� L�t tG�,(c� ""� iA_r 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. 9. 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. LocateL these facilities on the site plan and differentiate proposed facilities from existing facilities. `� 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.] 11. Describe the performance goals and standards applicable to the project. ;r r� .-.e.rt15 �1F ('�vv�` •� r' 1�'1(r�✓lP 1✓VLCv"l ' )i—ACL. 12. Describe the flow control system. I VI stormwater site plan template—rev.10/1/2003 6 • • 13. Describe the water quality system. < /VA = 14. Describe the conveyance system analysis and design. /////A 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. { il� 1‘ U - .1� r, �� �C� . y ry La. ( 1-i 11.( tAv c G; `�- -G �; 1 z 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. jam-L L 2:'(J la dii- <a2*✓L. C=, h C IA-) 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. 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. t 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. 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 SW PPP 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. trn r�r k-1 M. �i l( ut.. rt y x .. ►.v� -\ S f't -e-S r7- w t✓X,`.lP ,!z l r�.r n c.�v�Ck `'L�e. IrD<Jl ; f �. • 2. Establish Construction Access. OrvAA !1 Ir < via s x/LA,l( a v.:c,:_ - b act .f „sh k tk-uQ c c F �) 3. Control Flow Rates. vu� w zx,rr t e t-r fr \[Li t(&c 1-•cck. jrrc .t t� cifc SSA 0..c 1F-0-h0v-t 4. Install Sediment Controls. L0e_ ,i �C �� :. �L�: SS 05 ' fl�tn�t �_\ -(__c �},c`•l 5. Stabilize Soils. b t� r f ,_C.L i r s u,t- S t-�- �;ry 1'Er" c in.p ill U c l tit h o v-t . 6. Protect Slopes. N1 7. Protect Drain Inlets. stormwater site plan template—rev.10/1/2003 8 ! • 12 Required Elements-Construction SWPPP(continued) 8. Stabilize Channels and Outlets. APR 2 4 2006 9. Coni rol Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). i u.L...tiv-N1l V--Ait.e rvku v. 0-r1 1n0. ay cX;&v t%C31 err\ Ck kAek Y to v t kv r- 1 . VJ'vl\c i t„9DS i k-c- � Qvv,.. U✓�CcpY1�rz)q e d U-'O-k-c- c lcs 12. Manage the Project. fit rvv-e�1� : t1-.z. -i r`, ' --4-- r Q_ �t-e w-rc----k S r�c- f t--�. r--sc.-- Co X.s : 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). �;u.{ c,, r�l y2 CA— Lt-i✓u- 1 1nck L v1O a((--te l-- 0✓i Suit c Q vkci.t i., cx r .E�s , b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 y{ards). 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. stormwater site plan template—rev.10/1/2003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. I 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). 5. Construction Phasing. a. Construction sequence " ` 1 1 j • >'ffV� 11- > • ]XjTi a 4! 5 >1 C LY, ] b. Construction phasing(if proposed) kii �Y 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. k 7. FinanciaVOwnership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. L , 1 t C'ti V V t (.�.IL Jk ,/ b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. l+ / �7 l7 c. Waterways. d. Runoff/Stormwater Detention Calculations/ I 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 owners of the affected property. / q/2-3/C14° (LANDOWN O .- ORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 12 stormwater site plan template—rev.10/1/2003 ��¢ ON cod JEFFERSO OUNTY �"; ,..._ '� ,� DEPARTMENT OF COMMUNITY DEVELOPMENT �` �' ii �' '= W I 1- '.4 621 Sheridan Street • Port Townsend •Washington 98368 ,0 > 360/379-4450 • 360/379-4451 Fax APR 2 4 2006 ', qs, e www.co.jefferson.wa.us/commdevelopment tiIN yy�� Master Permit Application MLA: o(p - I q Project Description (include 1r separate>> sheets as necessary): lC. V C�.vv\.t I(LtSICl-l.rlCJI-- Property Tax Parcel Number: ¶ 02. 1 1 ( e [ c Size: . , 3 5O Ct.C./4 5 (acres/square feet) Site Address and/or Directions to Property: I D3 I L uc..l&o..bubk. i"-d1 exInri o,-.�wPE G 3 2© Property Owner(s)of Record: W'11 i&in') a y A P&rn e(a. ..Q(4-r1 Telephone: it0 "1a Co -3L}t-I I Fax: email: Mailing Address: I oil i�,)ck.Aba-sk 12e1 L ex,nn°'r))U-isA 61_2320 Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit? (Check each box that applies) i/Building ❑ Variance(Minor;Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]** ErSingle Fami��l L__, ❑ Discretionary"D"or Unnamed Use Classification IR/Garage (Attached/Detached ❑ Special Use (Essential Public Facilities)** ❑ Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** •G.Commercial* ❑ Binding Site Plan ** • tT Change of Use ❑ Long Plat** fl Address ❑ Road A roach ❑ Planned Rural Residential Development(PRRD)/Amendments** 13,16ropapa P.vJ vb t t 4\rrL.Ncri ❑ 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 ❑ Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT 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. Ij/� p Signature: .4..Z, 4'� A e�a�e c r ,— Date: ,-'// 7/?c (c. i f 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 efferson County development code.The Applicant acknowledges that he,she or it holds individual and non- transferable es o •' ility f eri to an y)ng with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: * /Q14"--4_.-/:—Z • e-e — Date: .:..3// J /j UU(4, G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc • 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 assu ing he responsi ility oft 'General Contractor for the proposed project. Signature:, 4'=-------- Date: 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: Fre Type: Bathrooms: Shoreline: Type of Sewage Disposal: Cu New Kt Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: 2..Y2_ Bank Height: ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: 7 %T _ lL ndividual System O Repair ❑ Masonry SEP Permit#,')/-y3 O Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well [t'fwo Party Type f Hea Proposed: 3 J/� ❑ Public _- C N .. 11,4t te3,4✓9 Total: - A Name of System: 4ls2-1n 'c 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 Pro ane Tank and/or A liance Installation ermit mark all items below tha J ❑ Underground Tank !, Above ground Tank Size of Propane Tank: { ❑ Heat Stove VCook Stove ❑ Woodstove I i Fireplace Insert L,I Hot Water Tan :. et- ton Otherf vwc c . Is this appliance being installed in a Manufactured/Mobile Home? Yes / 'etki,�5 / y 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 Propoaed For Office Use Only Amount Revision Main Floor Heated I L in EH BId App Review: �/o0 1 y L 3 ?1E32. `-) 2'Floor Heated 3Cj Consistency Review: d��w `y53 coZ f Other Heated Base fee: I 2024. 6 Mezzanine Additional Section: .------ Heated Basement Plan Check fee: I '7O Unheated Basement State Surcharge fee: 4 5° Other Unheated 5-0 t r,.i��n 5) Pot Water Review fee: `J"10 it) SUBTOTAL ') 35 q 0 io3-70 . o)I . Decks 911/Rd Approach fee: Q 1 is Ek.1�7l ----- Other TOTAL: $3L-10 I Receipt Number: 75 I `g �5 (01 sh/Check Number: rqo� ESTIMATED COST(REQUIRED) --- Date: 4 a41(10 •Fair market value of all abor and materials foundation t finish ), c 0 0 04p�/ / Initials: MS G:\PermitCenter\FORMS\DRD FORM Permit Application 12-30-05.doc z� . weu ss -f/3 "Frog.~rA e 4/0.r3,4 Z.I/ 4-1 Leo y �u o3� ��/ 1A/�!({`; g c•' �'s ht ...1 e pump ur i 4,' r . ...‹,_ 'a - ` s 4 col?eS A/es— `� es,,:. _ 1�� 4a ` �.1` w j n^'i i f _8� �var rx:;r,:,1. i • V,4. eL • • • .. ;"-'4;;;:------ --- Q i . 3 r y r • ' Ole- T / \\\ *U` y4°n ?pXc N` 'S = rvt�r S/ 0/ �fC\\ Cam..«S T P, Q ITV\\ - O APPROVED 4� FhGq�{e ck`�( SITE PLAN kil i ;�,� MAY 1 5 2006 1 , JEF O i :-. /d 0 f DEPT.OF CI )MENC. --- SIGNATURE. -!/'1 _ ----------- Stormwa er r , Require 'cr- N'-mt ILK PQY-cep # sire address "C v )( 5e- 502 )7-lo10 TrT/� • I /037 nv -,_ v< R4, !3r,af.No,� WA , ,2 e ors oA( /7 p con i.v 5 4-r-, ,. vt/Ll+LA-, J Q.„, .Z P(,:,. 79/--�u,I , lit Note.tet N':>.‘64.&ZI . o \ ' //<, ../: , . . .. 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