HomeMy WebLinkAboutBLD2006-00285 • PUILDING PERMIT APPLITPN MRLA06-00261 Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00285 Received Date: 5/23/2006
SITE ADDRESS: 549 THOUSAND TRAILS RD
QUILCENE, 98376
OWNER: ZELATCHED LLC PHONE: 253-752-7744
CIO FIDUCIARY COUNCELING
30 E SEVENTH ST, STE 2000
SAINT PAUL MN 551014930 THOUSAND TRAILS SHORT PLAT
SUBDIVISION: Block: Lot: 4
PARCEL NUMBER: 501041038 Section: 4 Township: 25 N Range: 01 W
CONTRACTOR: MITCHELL CONSTRUCTION PHONE: (360)796-2060
4246 DUCKABUSH RD
BRINNON WA 98320
Contractor's License MITCHC*1010E Expires 4/9/2007
REPRESENTATIVE: BOSWORTH-HOEDEMAKER PHONE: 206-545-8434
1408 N 45TH ST
SEATTLE WA 98103
PROJECT DESCRIPTION DEMO EXISTING BOATHOUSE
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2003 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
50--10(0
Type Amount Paid By: Date: Receipt: A 0 pproved/Dates-
Permit $51.00 LYK 05/23/06 81369
State Building Code $4.50 LYK 05/23/06 81369 JUL 15 2006
Total: $55.50
Jefferson County Planning
& Building Department
:Y• • : . ■ • I 1/ A . s.
TRANSMITTAL
To: Frank Benskin Date: June 29, 2007
Jefferson County DCD
621 Sheridan Street
Port Townsend, WA 98368
From: Jessie Temple Subject: Coyle House
Bosworth Hoedemaker LLC (Driscoll-Hoffman Hood Canal)
1408 North 45th Street Boat House Permit Revisions
Seattle,WA 98103
Permit No: BLD06-00286
Parcel No: 5010' 0 :
Attachments: Boat House Permit Set Revisions
Structural Calculation Package (Revised) ?p--)
Structural Detail Package (Revised) of(4)
Letter from Geotech Consultants, Inc. J 0 1
Revision&Renewal Fees ($204.00) ,,,\H
Frank:
As we discussed last week,we are now proposing to renovate the existing boat house structure
rather than to construct the new building previously permitted. Attached for your review are permit
revisions to this effect. We propose to retain the existing slab-on-grade and CMU walls, to cut new
openings in the existing walls for new doors and glazing, and to frame out new interior walls and a
new roof structure to match the existing. A letter from Geotech Consultants, Inc. regarding the
reuse of the existing slab and walls is attached, together with structural drawings and calculations.
Also enclosed is a check for$204.00 to cover both the permit revision and the permit renewal,as
the existing permit is about to expire.
Please note that no changes to the existing use, footprint, height or character are proposed and that
we are submitting only those pages that reflect changes.
If you have any questions or need additional information,please call me.
hanks,
es.ie Temple
jess'e@bosworthhoedemaker.c m
1408 North 45th Street Seattle,Washington 98103 206 545 8434 f.206 545 8433
•
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00285 Received Date 5/23/2006
SITE ADDRESS: 549 THOUSAND TRAILS RD Issue Date 7/13/2006
QUILCENE, 98376
APPLICANT: ZELATCHED LLC PHONE: 253-752-7744
C/O FIDUCIARY COUNCELING
30 E SEVENTH ST, STE 2000
SAINT PAUL MN 551014930 4
SUBDIVISION: THOUSAND TRAILS SHORT PLAT Block: Lot:
PARCEL NUMBER: 501041038 Section: 4 Township: 25N Range: 01W
CONTRACTOR: MITCHELL CONSTRUCTION PHONE: (360)796-2060
4246 DUCKABUSH RD
BRINNON WA 98320 3g
Contractor's License MITCHC*1010E Expires 4/9/2°0779g
6-4379
OWNER, ZELATCHED LLC PHONE: 253-752-7744
if different: C/O FIDUCIARY COUNCELING
30 E SEVENTH ST, STE 2000
SAINT PAUL MN 551014930
PROJECT DESCRIPTION: DEMO EXISTING BOATHOUSE
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 7/13/2007.
REQUIRED INSPECTION:
FinalApproval:
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
APP(00'20k Sck p\arr\
• •
SPECIAL CONDITIONS FOR CASE#BLD06-00285:
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on July 11, 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:
Type 1 Marine Shoreline (conservancy), Category II Wetland, eagle habitat(PHS &
Heritage), landslide hazard, Susceptible Aquifer Recharge Area, and coastal SIPZ.
2.) This proposal is to re-construct a boathouse in same flat upland (i.e.landward of OHWM)
location between Hood Canal and a Category II wetland as the existing boathouse
constructed in the late 1960's.
The structure does not conform to the current wetland setback requirements. However,
because it was established prior to the adoption of the UDC (December 2000), it is
considered a non-conforming structure and is not subject to the Environmentally Sensitive
Area (including wetlands) requirements as per Section 18.15.215 of the Jefferson County
Code (JCC). The repair of structure is also an exempt activity under section 18.15.335(a)
of the wetland section of the UDC, provided that the modification does not change the
character, scope, or size of the structure.
Shoreline issues are addressed by the Shoreline Exemption Permit (SDP 06-13) required
for this proposal.
An Eagle Management Plan signed by WDFW&the landowner has been prepared for
this property. The structure is located within a flat area is not designated a landslide
hazard. Because the use of the structure will not change issues related to susceptible
aquifer recharge areas are not a concern. The accessory structure (boathouse) does not
require a ground withdrawal, and stormwater will be infiltrated on-site. Therefore, coastal
SIPZ issues are addressed.
3.) Existing Shoreline and Wetland buffers that contain native vegetation shall be maintained
in their natural condition, however, minor pruning or alteration of vegetation may be
permitted as long as the function and character of the buffer are not diminished.
4.) Among the native conifer species which may be used in buffers or for re-vegetation
include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow (Saliz Lasiandra), and Scouler's Willow (Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry(Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray (Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sambucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry (Vaccinium Parvifolium).
5.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat
management plan.
6.) The applicant is proposing to create or add 600 square feet of impervious surface and
600 square feet of land disturbing activities. Sections 18.30.060 and 18.30.070 of the
Jefferson County Unified Development Code require that your proposal comply with
Construction Best Management Practices (attached).
!
7.) The project shall adhere to the Best Management Practices (BMPs)to control
stormwater, erosion and sediment during construction. BMPs shall address permanent
measures to stabilize soil exposed during construction, and in the design and operation of
stormwater and drainage control systems.
8.) Jefferson County determined that this proposal is categorically exempt from review under
the State Environmental Policy Act (SEPA) pursuant to WAC 197-11-800(3).
9.) The site plan as submitted with the Shoreline Exemption & Building Permit applications
(SDP 06-13, BLD 06-285, & BLD 06-286) on May 23, 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 July 11, 2006 shall be resubmitted for review and approval by
Jefferson County Department of Community Development.
10.) This approval is for the reconstruction of a boathouse 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.
11.) The Development Review Division finds that this proposal is consistent with Shoreline
Management Master Program Section 3.402(6) (JCC 18.25.090(6)), which is normal
repair and maintenance, and is consequently exempt from the substantial development
permit (SDP) requirements. Exemptions from the substantial development permit
requirements do not exempt a proposed development from compliance with the
applicable policies and standards of the Shoreline Master Program or other applicable
Federal, State, or local permit or license requirements.
12.) Work within the jurisdiction of the Shoreline Master Program other than as described
above shall receive separate review from this Department.
13.) The development shall be essentially the same as the original in location, size,
configuration, and external appearance.
14.) No fill or other material may be placed in the waters or intertidal areas of Jefferson
County.
15.) All lumber and other materials treated with preservative shall be sufficiently cured to
minimize leaching into the water or shore bed, in accordance with the Best Management
Practices approved by the Washington Department of Fish and Wildlife.
16.) The proposal is located within 200 feet of a Type 1 shoreline (Hood Canal), which is
designated Conservancy by the Jefferson County Shoreline Management Master
Program (SMMP). The proposed unheated boat storage building is considered an
accessory use of the residential use of the property (Designated Rural Residential by the
Jefferson County Comprehensive Plan), and is required to meet the Residential
Development (Section 5.160 of the SMMP). This is lowbank shoreline with a bank less
than 10 feet in height. There is a 30 foot setback from the Ordinary High Water Mark
(OHWM)for new structures. However, this setback does not apply to the
repair/reconstruction of structures that meet the normal repair& maintenance provisions
found in Section 18.25.090(6) of the JCC. The proposal meets the requirements of the
SMMP as reflected on the site plan received on May 23, 2006.
17.) This parcel is Lot 4 of the Thousand Trails Short Plat recorded by the Jefferson County
Auditor.
This parcel is designated Rural Residential 1 dwelling per 5 acres by the Jefferson
County Comprehensive Plan adopted August 28, 1998.
18.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
19.) There is a 20 foot setback from the edge of the right-of-way of Thousand Trails Road
(C409109), which is located to the east. Based on the location of the existing boathouse,
the proposed boathouse shall be 15 feet 6 inches from the Category II open water
wetland located to the north, and 10 feet from the OHWM of Hood Canal to the south.
There is a 5 foot setback from the western property line.
20.) The building height is not to exceed 35 feet.
21.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
• •
22.) This proposal includes a shoreline exemption (SDP 06-13)for the reconstruction of the
boathouse under normal repair& maintenance section of the SMMP; a demolition permit
of the existing boathouse (BLD 06-285); and a building permit for the construction of the
new boathouse (BLD 06-286).
There is an existing house & septic system on this parcel. There is also a proposal for a
new septic permit(SEP06-71) currently being processed for this parcel.
I:\F_BLD_Permit_Propane.rpt 10/29/19£
• •
Q� GION CLjgf\
"k.O "I" 44\ Olympic Region Clean Air Agency
2940-B Limited Lane NW
,,--' Olympia, WA 98502
\ =:; ORCAA '� (360) 586-1044 or 1-800-422-5623
Fax: (360) 491-6308 www.ORCAA.org
Notification of Demolition Permit
It is unlawful for any person to cause or allow the demolition (or major renovation) of any structure unless all asbestos-
containing materials have been removed from the area to be demolished. Work shall not commence on an asbestos project
or demolition unless the owner or operator has obtained written approval from ORCAA. A written application for a
demolition shall include a certification that there is no known asbestos-containing material remaining in the area of the
structure.
Project Site Address: 54 k TNoQsA141> County: �FF�Rsat�l
City: G2 State: Way Zip: $33-4b
Starting Date: ,��� �� Completion Date: ,�t_� la,Z.006,
*(There is a 10 working day advance notification period from receipt of permit application)
Property Owner: $t��peasc_oi..L. t\ t=Fr .,yTelephone: 2S3.3-s2. Fax:
Mailing Address: 4(07-2 t•kC3 rN V 12- E- ST>��
City: TekG-O t State: WA% Zip: 78 9c)�-
Demolition Contractor: rc���t.�. Cars-t R�,c_�to� State License#: 1,1k-rc-4c.* lc—E.
Mailing Address: As-it,, D�k�,gesF} lzogp
City: $¢1NNott State: 14 At Zip: ,837-4!.
Contact Person: tom' nt-1-4.4 t,t_ Telephone: 3to0 Zol.v Fax: -0.101E_
YES NO
Demolition by Wrecking or Dismantling?($25.00 fee)check# nonrefundable
Training Fire Demolition? (If yes, attach fire department request for training fire)
Renovation,Alteration, Remodeling, Maintenance, or other Construction?
Asbestos found or suspected*
*An ORCAA "Notice of Intent to Remove or Encapsulate Asbestos" form and appropriate fee must be submitted prior to any asbestos
removal work. Asbestos removal projects involving demolition must be preformed by a Certified Asbestos Contractor and all friable or
potentially friable asbestos must be removed before any demolition begins. Refer to ORCAA Regulation 1 Article 14 for additional
requirements that may apply.
Asbestos Survey Completed by
AHERA Certified Inspector . >LAa 1t -TA,-(Lo¢. \LGg,
Certification # k
This approved permit must Excise.. Certification of the Asbestos Survey must
be available at the job site Ptocessiag-Fee accompany this form
F:\COMMON\Form s\asbestos\DemoPerm it.doc
Rev. 10/22/02
• •
Date: Initial `ccto�cra.v Date Application Received
Amended: ❑ ��ve �,R 2940 B Limited Lane NW
°`. "� Olympia, WA 98502
Completion: ❑ � Phone: (360) 586-1044
0R`CAA,/ Fax: (360) 491-6308
Annual: CI $500 . .•
!.. www.OR CAA.orq
Agency Use Only
Permit Application for an Asbestos Project
A. Project Type: 1. ❑ Asbestos Removal _ 2. ❑ Renovation _ 3. ❑ Maintenance
4. ❑ Encapsulation 5. (-Demolition 6. ❑ Emergency 7. ❑ Other:
B. Property Owner:
' t LA-- 1;>9--1S4.v t-L.+ LvsA VSter•F t'.Lai.1 Phone: (r- -7$2. q1
Property Owner's
Mailing Address: A(02Z tJorsTA NMF-1> STQEF-T City:TAc-ctMA State: W k Zip:"a"ta7
C. Asbestos Contractor: Contractor Owner/CEO:
Mailing Address: N /
Phone: ( )
City: State: Zip: Fax: ( )
D. Site Address:
541 -['t-kouiSaAt> "TRAit,.s tZ-aQ,D City: CAutt..C.>ctile.. State: WA% Zip:/a3-fio
Project Manager or
Contact Person: GG.Iz 'f bAclu o.ao Q $c'44o tz-TT 1\oet.E.A IAK Phone: (Zo(,) S95! 9131
E. U Asbestos Survey or No.of Structures: Date Asbestos Survey Conducted: Was Asbestos Found?
❑ Mat'l Presumed: ❑Yes
I S• lc .c.( la If No,Attach Survey
AHERA Building AN AHERA SURVEY ISREQUTRED BEFORE ALL DasIOTJTTON Certification No.: Expiration Date:
Inspector Name: PROJECTS
.,reo.a te..-Tie.-e -° -- 1F-L e 1 oZc c -.1 I • `)' • 6-4—
F. Demolition No.of Structures: Start 1 ❑ Training Fire(List Fire Dept.as demolition contractor below)
Information: I Date: J U .-( I ❑ Ordered Demolition(attach copy of Order)
Demolition Print crane here;enter mailing address in box Jon back of form. If training harn,enter name offtre department here
Contractor: ig-02b IA tTc-•4 Phone:( )
G. Asbestos 1 No.of Structures:(see Start Date: Completion Wk.Days: M T W Th F Sa Su
N
Project back if> 1) Date: Hours:
Information:
Will all asbestos material be removed by
Total Quantity to be Removed: Square Feet Linear Feet project completion?❑ Yes ❑ No
Thermal System Insulation: r❑Boiler/Furnace Ins. I V Duct Ins. U Pipe Ins. Other:
Surfacing MI: ❑Fireproofing r❑Paints Plaster U Textured Coatings Other:Mel:
Misc.Mat'l: U Cement Bd. Li Cement Pipe U Flooring Mat'l U Roofing Mat'l Other:
H. Asbestos/Demolition Project Categories: Notification Waiting Period NONREFUNDABLE
FEE
1. UResidential Dwelling Asbestos Removal Project Prior Notice $25
2.--EMemolition 10 Working Days $25
3.—❑less than 10 linear feet or less than 11 square feet Prior Notice $25
470 10-259 linear feet or 11 - 159 square feet 10 Working Days $100
5. -❑260-999 linear feet or 160—4,999 square feet 10 Working Days $250
6. U 1,000-9,999 linear feet or 5,000-49,999 square feet 10 Working Days $500
7. -❑10,000+linear feet or 50,000+square feet 10 Working Days $1,000
17DAnnual Permit(Limited removal,additional permits,contact ORCAA) Prior to start of New Year $500
9. ❑Emergency Project Prior Notice $50
10. ❑Amendments(no fee for Is'and 2nd amendment) Prior Notice $25
I. I do hereby certify that the information contained in this notification,and supplemental data Payment received date:
described herein,is t the best of my knowledge accurate and complete. I shall not cause or allow Reviewed date:
any asbestos project or demo i on a vities to begin until the appropriate waiting period has Reviewed by:__
elapsed.
Permit Number:_
Date faxed/mailed notification to applicant:Signature: Date: S I 9,o(p
For Compliance With Regulation 1,Section 14-Asbestos
Print Name: . 1-SVV.- 40E-p NAI4A.E'-'� n Re resenti1 p g S1 c-L-bR-1Sco Cam i- Agency Use Only
Rev.07/07/04e,��6�Tti- �E- .r` 1�tS4 1-}or ry,,t1
• •
The Olympic Region Clean Air Agency is the local air pollution authority for Clallam,Grays Harbor,Jefferson,Mason, Pacific,
and Thurston Counties. The tjympic Region Clean Air Agency's Regulation 1, Article 14, requires advance notification be
submitted to the Agency, on Agency-provided forms, for any asbestos project and for any demolition proiect,_regardless of
asbestos content, involving any structures. Notices of Intent should be mailed or hand delivered to the Agency (address on
reverse side) with the appropriate project fee. An Agency representative will review the notification, and if it is completed
correctly a copy will be returned by mail or fax within 3 to 5 days to information provided in box C and box J. The returned
copy will be your valid notification.You must have an approved permit prior to job commencement.
J. Demolition Contractor: Owner/CEO:
t'1 -CL+ � lvasTw��T�r�, 12-oe, %rr E-u—
Mailing Address: QZg b t'oc'ke_`$Os+` �`p Phone:(3`0)�9(e •�4*c)
City: a-tN+.1�ar r
1 State: "-IQ Zip: 4)832-42' Fax: ( ) ` 11F--
GUIDELINES FOR SUBMITTING AN APPLICATION TO PERFORM AN ASBESTOS PROJECT
Enter all applicable information accurately and completely. Incomplete Notices of Intent will be returned.
Box A.Check all appropriate project type.
Box B. Enter the legal property owner information.
Box C. Enter the asbestos contractor information, or "not applicable" (N/A) for demolition projects when no asbestos-
containing materials are present. For a Residential Dwelling asbestos removal project, list the property owner doing the
asbestos removal(include property owner's mailing address).
Box D. Enter the asbestos removal or demolition site address. For a Residential Dwelling asbestos removal project where the
property owner's mailing address differs from the site address listed in Box D, a letter must accompany the Notice of Intent
verifying that the structure located at the site address is currently being used as the property owner's domicile. Multiple
asbestos/demolition projects involving more than one structure must be submitted in accordance with the ORCAA Regulation
1,Section 14.05(a)(8).
*Residential dwelling (ORCAA Article 14, Section 14.03 Definitions) means any non-multiple unit building
containing space for uses such as living, sleeping preparation of food, and eating that is owned, used, occupied, or
intended or designed to be occupied by one family as their domicile. This term includes houses,mobile homes,trailers,
houseboats, and houses with a"mother-in-law apartment"or"guest room." This term does not include structures that
are demolished or renovated as part of a commercial or public project. Nor does this term include any mixed-use
building, structure, or installation that contains a residential unit, or any building that is leased or used as a rental.
Box E. Enter the asbestos survey information or check material presumed(for asbestos projects only). An AHERA building
inspector must conduct an asbestos survey prior to any demolition project(i.e., the wrecking, razing, leveling, dismantling or
burning of a structure, making the structure permanently uninhabitable or unusable). A copy of the survey results shall
accompany the application.
Box F. Enter the demolition project information. If the structure is to be used in a training fire, list the fire department
responsible for conducting the burn as the demolition contractor in Box J. If the property owner has been ordered to perform a
demolition by a government official,submit a copy of the order from the appropriate official.
Box G. Enter all asbestos project information or enter"N/A" for demolition projects with no asbestos removal required. All
multiple structure asbestos projects must be submitted with a work plan,map of the structures, complete site address, type and
amount of asbestos material to be removed from each structure,AHERA asbestos survey,and work schedule.
Box H. Check appropriate project categories in boxes 1 through 8. Asbestos project fee does not include demolition project.
An additional $25.00 is required for a demolition project. Emergency notifications must be submitted with a letter from the
property owner explaining the necessity for the emergency. Emergency demolition notifications must be submitted with a
letter from an authorized government official or a licensed structural engineer documenting that the structure is in imminent
danger of collapse.
Box I. Sign the notification certifying the accuracy and completeness of the information provided on the form.
Box J. Enter demolition contractor mailing information(on back).
Mandatory amendments are required for changes that increase the project type, job size category, the types of asbestos
materials to be removed and work schedule changes. A $25.00 processing fee is required for all amendments* (1 e and 2nd
amendments have no fee requirement).
For technical assistance,or inquiries concerning notification and amendment status contact Dean T.Nguyen at(360)586-1044
Rev.07/07/04
• • •
SON 1 ;-- 11;, .1.--.:, L /; i. rf ,
(."---,
c0r,. JEFFERSON COUNTY )I "
` DEPARTMENT OF COMMUNITY DEVELOPMENT {E !
MAY 2 3 2006 Js
621 Sheridan Street• Port Townsend •Washington 98368 ,
360/379-4450 • 360/379-4451 Fax 1
�q�,iinsi 0'� www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: (''(n- 1
Project Description(include separate sheets as necessary):
•17ti,L%1) VAS i f?",_±1-ri-ILAYAZ—
Tax Parcel sQ`o 10.. Property
Number: Size: ,6$ (acres/square feet)
Site Address and/or Directions to Property: 5415TNouStstAp-1-12.AtLL 32-e1a-1>
Property Owner(s)of Record: �tLL UR‘sc.ow t Lvsk qav-fha.,l 1 Z t.--ATr_-•t-- i L - -
Telephone: 25 3-1-52.71'fii Fax:
email:
Mailing Address: Qto Z2 W- V -vf_._ S-r.1Titcatla 1!1+c "210-3-
Applicant/Agent(if different from owner):' s p.-r 4- 14(3E1a4=_et,w Az_
Telephone: Zc(p-SAS. $939 Fax: 2.0(0.-54:5-•8-4133 email:col rc 6a_4 Let• co.,.
Mailing Address: 1A09 t-1 •-i$T* ST)S W 1r14\ 98 l,-b
What kind of Permit?(Check each box that applies)
/B ilding ❑Variance(Minor,Major or Reasonable Economic Use)
Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
❑ Single Family 0 Discretionary"D"or Unnamed Use Classification
Y3.o*ZT 4ovsE. ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑Short Plat**
❑Commercial* ❑ Binding Site Plan**
❑Change of Use 0 Long Plat**
❑Address ❑ Road Approach ❑Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ,$'Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Variance
❑Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑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 o 1,452..--r �. r‘t.V-->r•t2- to act as my agent in matters relating{ to this applicationfor permit(s).
OWNER SIGNATURE _ Date: y l�6/z
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 attorneys 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 provi acce and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and an it later' specti .Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature:
_ Date: 5. 19 . o 4
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 •ct"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issu-• will not 'date the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even I ou ark: in nce *th the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf-•. e • ponsi. for.. ering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: J���.,,,.• Date: .S 1 9•.6
• • • •
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 be assu1ning the responsibility of the General Contractor for the proposed project.
Signature: 1J A Date: tJ'Ar
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
,I tT-A t.t� C_Am '("s-.0c__- - (Sip) 19(P. 2 t ( 5(.0) 3-7 C. .Za(oo
MAILING ADDRESS: 97_1(p •D�ti" goAD113rtN�.1a,1 vih "S'5zn,EMAIL:a„4,4xs i rMee4r-‘t,1.^„..ne.-l-
CONTRACTOR'S LICENSE WAINS
NUMBER: IA NUMBER
ARCHITECT/ENGINEER: st..b¢-T►-}- � �� 1t PHONE (2,o(p)5`5'Si*5•4 FAX:(?p4, )S-1SSg33
MAILING ADDRESS: 140b Rolicril �ST4 ST.,SE-A111..V.. IAA, "sko 5 EMAIL C_1fcy®t:,,sr,641.troede...-+aker•com
Project Type: F me Type: Bathrooms: Shoreline: Type of Sewage Disposal:
/ New ,iIWood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: ± Bank ❑ Community System
O Alteration/Remodel Concrete Total: Height: ❑ Individual System
O Repair 0 Masonry SEP Permit# nttp.
jai Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
T f Heat: Proposed: ❑ Public
I� Total: i Name of System: tJ tk
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: i ibk.
❑ Underground Tank 0 Above ground Tank Size of Propane Tank:
O Heat Stove 0 Cook Stove ❑ Woodstove 0 Fireplace Insert ❑ Hot Water Tank 0 Pellet Stove 0 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,
includin r the reserve area.
Square Footage r , Ce'Use Only F_ , 1j `,:, -- til,V -
Current Proposed L�" `- f„ra A:: k t¢KM,z} 4�s,`.
. r� f y. .t tt 7.gfx�y 7 L{
Main Floor ., consistency Review: r,"`` s iii ' �'°". ' � f�.a-
m
-..s �+ ay.»it.�x 'y'w4{,.xa1a, i�.
2' Floor s,Base fee: ` t '`�� " S " t »
3' Floor ' 'Additional Section: � 1 `W 14 .`„� , �
Mezzanine: :f'ian Check fee: $�, . ` ,,, F
Heated Basement ' State Surcharge fee: `" � :'•$' 'IV ax" �s :"
e^J�f�.S . �Y ,..L Rk
Unheated Basement Pot Water Review fee: - 14,A
- Mj' 'F `7.-ov 3
,- �y.5 .1tMl.4X k Y
Other Unheated 911/Rd Approach fee: . ; t i Pit ' r .
Oslo t', ; , 2 '-. ,.x
Garage/Carport �TOTAL $ / '
Decks x�
Receipt Number: 5'_ m` ; >. -, . . fo
Other Cash/Chec(k Numbe" ': 0 ,. t
ESTIMATED COST(REQUIRED) Date: '; w=• , ' . n y .
.Fair market value of all labor and materials foundation to finish t .-i ' ' +„• :i t f ;
-initials; /"/ ,.;r a, AS
u,.