HomeMy WebLinkAboutBLD2006-00264 • •
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 #: BLD06-00264 Received Date: 5/16/2006
SITE ADDRESS: 42 S ANDREW AVE Issue Date: 7/17/2006
PORT TOWNSEND, 98368
APPLICANT: GARY JENSEN 3 -`10
COLLEEN JENSEN !l��--�Jc,
10964 RHODY DR
PORT HADLOCK WA 98339-9748
SUBDIVISION: IRONDALE Block: 140 Lot: 13-16
PARCEL#: 962114003 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215
DEALER 1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License KOZELHS02:7C3 Expires 1/6/2007
PROJECT DESCRIPTION: NEW MFH
SERIAL NO. RFLCH2AG224806166
MAKE: FLEETWOOD
YEAR: 1986
SIZE: 36 X 28
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 7/17/2007.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY_T YOUR PROJECT
Setbacks/Footing (CONTIN OUS O TIN O r PADS USED): /—a;
vf&— �Ns n,J1V 7 /9 Ok
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Stormwater FINAL Approval: /02-
Blocking/Plumbing: I"1rd ft,e c t T7?� Z'(� R- b)41 9,9-z p-G6
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Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval:
Final/Skirting/Vents/Porches/Steps1 -z
HEALTH DEPARTMENT AND PUBLIC W RK 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
BUILDING PERMIT APPLICAT PN ML vy 248
Review T Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00264 Received Date: 5/16/2006
SITE ADDRESS: N?-S ANDREW AVE
PORT TOWNSEND, 98368
OWNER: GARY JENSEN PHONE: (360) 385-4819
COLLEEN JENSEN
10964 RHODY DR
PORT HADLOCK WA 98339-9748 IRONDALE
SUBDIVISION: Block: 140 Lot: 13-16
PARCEL NUMBER: 962114003 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215
1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License KOZELHS027C3 Expires 01/06/2007
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI NEW MFH
SERIAL NO. RFLGH2AG224806166
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 5,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 2 Prop: 1
Total: 2 Total: 1
Routing Date:
\12, (.61
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $163.00 KAS 05/16/06 81182 AFROVE
Potable WaterApplication $55.00 KAS 05/16/06 81182
Total: $218.00 JUL 11 2006
Jefferson County Planning
& Building Department
Cal
JACK WESTERMAN AP Jefferson C iii-Courthouse
ASSESSOR 1'/l Box 1220, Port Townsend. 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: - A 4,1,
ADDRESS: /D 96, 4/ f21)L Ow_ ,j/Z+• gA�1 c(lc t-)ft 9.8'3 >`l
PHONE NO. 36,c;l �5.5- y. I9
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous o i !4 nE oe$ti of a mobile
home. This will help our office determine whether tha#�! 64b c 1i� iie its already on the
tax rolls in Jefferson County er if it has been moved to this county from another area.
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I)MOBILE DOME DATA:
(A)MAKE f Lf.E tWDC)p (B)MODEL J[f fERS N COUN�' PCP
,may (C)YEAR hic576
(D) LENGTH 7 (E)WIDTH . (F)SERIAL# 6 ' H R e-4.*(/O oc'I
(G)YOUR PURCHASE PRICE (Do not include sales tax)- )OC 0 PURCHASE DATE 4///U(p
2)PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE J- I 1 1i di(r )
ADDRESS 1 3 -I ( ! 1 1i a) S E-7 o l 4Y u 11 ]2£ . % ��
(B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year. L,.12(-} T'
IG`r Cr}K4 PjRGC PE-(-4j'z--4-- v1i
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes O
(B)IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Space#
(C) IF NOT LOCATED IN MOBIL HOME PARK:
NAME OF LAND OWNER: r R & 1V_jF
LOCATION ADDRESS 7 Pk?cc-
REAL PROPERTY PARCEL #/DESCRIPTION tr 1/'y(i«3
Signatur f a licant
THANK YOU FOR YOUR HELP!
JO COSSELL, Property Technician -
• •
SPECIAL CONDITIONS CASE # BLD06-00264
1.) PRIOR TO SCHEDULING A FINAL BUILDING INSPECTION THE PROPERTY OWNER
WILL PROVIDE THE DEPARTMENT OF COMMUNITY DEVELOPMENT WITH A FULLY
EXECUTED AND RECORDED JEFFERSON COUNTY NO PROTEST AGREEMENT.
THE AGREEMENT STIPULATES THAT THE OWNER WILL NOT PROTEST FUTURE
DEVELOPMENT OF S. ANDREW AVENUE OR THE ASSOCIATED COST SHARING
OF CONSTRUCTING THESE IMPROVEMENTS AND APPURTENANCES.
2.) The application was reviewed by the Jefferson County Department of Community
Development staff on June 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, the following ESAs were
confirmed to be present on the subject property: Special Aquifer Recharge Protection
Area (SARPA), Coastal Seawater Intrusion Protection Zone (SIPZ).
3.) 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.
4.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within Susceptible
Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit (4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
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.) 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.
8.) 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.
•
9.) VOLUNTARY MEASURES OFtOASTAL &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.
10.) 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.
11.) The applicant is proposing to create or add 3,264 square feet of impervious surface and
3,264 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson
County Unified Development Code requires the project applicant submit a stormwater plan
meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater
Management Manual for Western Washington. The stormwater plan shall address
measures to control stormwater, erosion and sediment during construction and shall
address permanent measures to stabilize soil exposed during construction, and in the
design and operation of stormwater and drainage control systems.
12.) 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.
13.) A Medium Stormwater 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.
14.) 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).
15.) The revised site plan as submitted on June 28, 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 June 28, 2006 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
16.) This approval is for a manufactured 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.
17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
18.) 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).
19.) Pre-existing legal lots of record less than one acre in size in Rural Residential districts are
subject to the stormwater requirements in UDC Section 6.7 and must meet the"Area of
Impervious Surface Coverage"to the maximum extent practicable as determined by the
Administrator." Lot coverage is defined as amount of impervious surface, which includes
rooftops, driveways, concrete, etc.
20.) Setback from S. Andrew Ave. right-of-way is no less than 20 ft., side and rear setbacks
are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more
restrictive setback shall apply.
21.) 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.
22.) 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.
23.) Stormwater shall be retained and infiltrated on site. The owner shall control all
sedimentation and erosion on the property.
24.) The building height is not to exceed 35 feet.
25.) This is a legal nonconforming parcel designated as Rural Residential 1:5 under the
Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998.
26.) A septic permit (SEP06-00148)was approved June 20, 2006 for a capacity of 240 gallons
per day.
27.) S. Andrew Ave. (P586) is a private road. A road approach is not required and an address
of 42 S. Andrew Avenue has been assigned to the parcel.
28.) A minimum of two (2) on-site parking spaces is required for the single-family residence.
29.) This parcel was created through Irondale#6 under AFN 30490, recorded June 28, 1910
Volume 2, page 139 with the Jefferson County Auditor's office.
30.) A Declaration of Restrictive Covenant was recorded June 16, 2006 under AFN 511261
with the Jefferson County Auditor binding lots 13 thru 16 of Block 140, Irondale No. 6 for
the purpose of meeting bulk and dimensional requirements and minimum land area.
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STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# NO 'C Lt PROJECT/APPLICANT NAME: ( /t
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 stomiwater 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.
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2. Describe the existing topography. Indicate contours on the site map.
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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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. L f
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6. Describe any excess levels of noise generated by the proposed use or activity: "`f 4>"
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stor mvater site plan template—rev.10'1/2003
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7. Describe signifi nt geoaphic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
s st$e s,et )on the ite. Indicate location on the site map.
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L.,„�:;. 8""�"bescribe the general vicinity of the site, including adjacent land uses and structures,utilities, roads,and sensitive/critical areas
(streams,wetlands,lakes,steep slopes,etc.).
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Permanent Stormwater Control Plan r'rh -/ ,A s/tY 3'a .1 i
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. Locate these facilities on the site plar`nn and differentiiatte. proposed facilities from existing facilities. t
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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.]
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11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system. ,?N,
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stormwater site plan template—rev.10/1/2003 6
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13. Describe the water quality system.
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
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17. Describe the proposed surfacing material.
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18. Describe methods for restoration of the site.
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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.
21. List other necessaryapprovalsrequiredby regulatory g
permits and as other re ulato a encie �I�fti�`�per#rttts or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-relateduirements,describe those conditions or
restrictions here.
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stormwater site plan template—rev.10/1/2003 •
7
411 •
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.
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets. r1 L i t tl u u t U u�di s i to tsd
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stormwater site plan template—rev.10/1/2003 8
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12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site. "'
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stormwater site plan template—rev.10/1/2003 •
9
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b. Description of special requirements for working in or near environmentally sensitive areas.
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).
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5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
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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. I. �f K , 4
b. Diversions. j]
c. Waterways.
d. Runoff/Stormwater Detention Calculations I i FEES Al `i i?I i'
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stormwater site plan template—rev.10/1/2003 10
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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.
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"(LANDOWNER_ AUT REPRESENTATIVE SIGNATURE) (DATE) /
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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storrnwater site plan template—rev.10/12003 12
• •
, ON cN JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
A O� www.co.jefferson.wa.us/commdevelopment
S�NOS 1—
Master Permit Application MLA: Qt(�"_)Li8
Project Description(include separate sheets as necessary):
K, _r R 1 1 , )( (i m o\t \ t: Ir1 c r, , "i / S c t.., 1 i r
Property I c ,cx:c�
Tax Parcel Number: (� �p ,`� j 1� Size: j ()C X 10� (acres iliare feet)
Site Address and/or Directions to Property: �(` ( `\,,k- r-,tJ LA r,\,/ L, L,..(4,o,t) ('RSe AO( LC4 I o, / it.)Qv?c i1 ;Property Owner(s)of Record: ,- .c /
Telephone: jtor)/�'i(s,s- '-$/9 Fax:,3 L.l?/.3 g s- ,.9 j? email:
Mailing Address: /(?9(,,L/ art,{ Ole j_..t i"171 r><kt L.A.)Pc91,3 ,
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit? (Check each box that applies)
f Building R lj �iC�Tf�Y1pq/ariance (Minor, Major or Reasonable Economic Use)
Jt ❑ Demolition Permit J a 11e 1l .31.4onditional Use[C(a),C(d),or C]**
❑ Single Family 0 Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached �v 0 Special Use(Essential Public Facilities)**
CS\Manufactured Home "�. 1. ' . Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use AIEFEEPSH C Uli J W Ong Plat**
❑Address i Road Approa EPPlanned
Rural
Residential Development(PRRD)/Amendments**
-0 Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management Li 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. _ , ,
Signature* t ..-,. Date: -V f jo/G' 6
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon onef 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 responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and s.gns and dates it below.
Signature:( (.k�xvJ i Date: /6A5 6
• •
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:. ......�.c-.,> �- Date: --i///, f 0 F.
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
,'<C 5C.)i Sk 3 / l c ( rl J`c,(e--re t.C 4_. ('X.tA3 g -� /5 (..:t'0 3 k5-9e/ < -
MAILING ADDRESS: 1 i i i Z ' —) EMAIL:
CONTRACTOR'S LICENSE -R.,ram-- ,T.c,_� _ ti tiJ 0 i t_i: Pt (l S 36.$ WAINS
NUMBER: NUMBER G `a
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
O New CIWood Existing: ❑ Sewer
Addition ❑ Steel Proposed: i Bank Height: ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: r L Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: fel Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: p Public t , P ,,C` ,tt" % Total: ")... Name of System: pLi S,_'
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 Ii Above ground Tank Size of Propane Tank:
❑ Heat Stove f7 Cook Stove ❑ Woodstove 1 i Fireplace Insert U Hot Water Tank l l Pellet Stove ❑ 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 Propoaed For Office Use Only Amount Revision
Main Floor Heated EH BId App Review: / G QC)
2n1 Floor Heated Consistency Review:
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement -4'( 1 it ` ) , ;' ii ) Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
CIO- OD
Garage/Carport (:' )' T til SUBTOTAL
Decks 0/Rd Approach fee: C3Q
Other TOTAL: $ (4,a3
Receipt Number: % $a
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: C I h(
•Fair market value of all labor and materials foundation to finish 5J l 4 l 6(p
Initials: CAN,
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