HomeMy WebLinkAboutBLD2006-00418 B"JILDING PERMIT APPLICATI• M Review eviewT0406
Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00418 Received Date: 7/19/2006
SITE ADDRESS: 1201 THORNDYKE RD
PORT LUDLOW, 98365
OWNER: CYNTHIA TOWNER PHONE: 360- $7-8731
PO BOX 351
KINGSTON WA 983460351
TRAILS END 2ND ADDITION
SUBDIVISION: Block: 13 Lot: 13
PARCEL NUMBER: 950101313 Section: 16 Township: 27 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NSFR W/ATT GARAGE & AIG 500 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 171,910.00 MAIN: 1,130
CODE EDITION: 2003 ADD'L: 636 HEAT TYPE: PRO
OCCUPANCY: R-3 HEAT BASE: HEAT TYPE: EEE
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: 5N OTHER: 232
GARAGE: 289 SHORELINE:
CONST TYPE: SETBACK:
DECK: 57
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: BRIDGEHVN
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 3
Total: 3 Total: 3
Routing Date:
nl 1910(o
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,396.95 LYK 07/19/06 83841
Plan Check $908.02 LYK 07/19/06 83841 ';
State Building Code $4.50 LYK 07/19/06 83841
Potable Water Application $55.00 LYK 07/19/06 83841 AUG 31 2006
Total: $2,364.47 Jefferson i ou,uy vIa;31,,,,,,
& Bui;;, '+i? {i epa:tment
•
BUILDING PERMIT
Jefferson County Department of Community, Development
621 Sheridan Street, Port Townsend WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00418 Received Date 07/19/2006
SITE ADDRESS: 1201 THORNDYKE RD Issue Date 08/31/2006
PORT LUDLOW, 98365
APPLICANT: CYNTHIA TOWNER PHONE: 360c8731
PO BOX 351
KINGSTON WA 983460351
SUBDIVISION: TRAILS END 2ND ADDITION Block: 13 Lot: 13
PARCEL NUMBER: 950101313 Section: 16 Township: 27 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NSFR W/ATT GARAGE &A/G 500 GAL PROP TANK
CALL IN FOR THE REQUIRED INSPECTI THAT APPLY TO YOUR PROJECT.
SETBACKS: Ok 9/12-/�O
UFFER: MO
Footing: OK, /sl-/a 9 fi.n- -gk e & 7/JC s . k 4/ earabar/ 4/M�/�X
Foundation:
o dation: DK 91/141406* /4)A.G771Jce/D11
Stormwater FINAL Approval: OK 4/25107#
Underground Plumbing: /'04
Underground Insulation: / �A /pJC 1 9� °"
Shear Wall : �� !� G4711�i�/o1JS j/ 27 O fr
Sheathing: aU/A!
Framing: Og 1I30I0-7, ,I� ��
Plumbing:?rerwerWA$ # I'J 6, 1-2.2-07 s5
f
Propane Tank/ Lines: 0. E E hue D1('3 07 FRoptla� APx"41
Insulation: &ALL Ftoozs #Cgf��,uc6 .- d?�µ �
� kg sue.d� ��2n/ter,4
Sheetrock: 6671 r Al e irAi 0 �o7,/
Septic Sytem Fi al Approval UST a obtained before final of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: .0( 1 r G%D y,/7,,
HEALTH DEPARTMENT AND PUBLIC WORKS lAPPRO AL RE. IRED 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
-- I
SPECIAL CONDITIONS FOR CAS• BLD06-00418 •
1.) 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.
2.) A Geotechnical Report dated September 29, 2005 prepared by Stratum Group was
submitted in conjunction with this application. The report addressed the stability of the
geologic hazard area. A setback of 30-feet shall be measured perpendicularly from the
top or toe of the geologic hazard to the proposed residence, except for at the far southern
boundary of the property where the setback should be at least 50-feet from the top of the
steep slope above the area of convergent topography.
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. 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.) 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.) MANDATORY MEASURES OF HIGH 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 FO,IGH RISK 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 requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106
for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e) of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter. Ave?) (.0 5Y5-rgH / Nar R 'eg°
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
11.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
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.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
14.) Not more than 2 unlicensed or inoperable vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or
more junk motor 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 or Chapter 18.18 JCC, and such storage shall meet the requirements of JCC
18.20.100, Automobile wrecking yards and junk (or salvage) yards. In no case, shall any
such junk motor vehicles be stored in a critical area.
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 Thorndyke Road right-of-way shall be 20 feet. Minimum side yard
setbacks shall be 5 feet. minimum setback from top of bank shall be 30 feet, except for at
the far southern boundary of the property where the setback should be at least 50 feet
from the top of the steep slope above the area of convergent topography.
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.
21.) ROOF RUNOFF AND ANY OTHER STORMWATER WATER RUNOFF SHOULD BE
DIRECTED AWAY FROM THE STEEP SLOPES AND DIRECTED INTO A
DISPERSEION TRENCH ON THE SOUTHWEST SIDE OF THE PROPERTY.
22.) THE SEPTIC DRAINFIELD SHALL FOLLOW THE SAME SETBACK
RECOMMENDATIONS AS THE HOME.
23.) NATIVE TREES AND PLANTS RITHE SLOPE AND WITHIN THE SETBACFc"BUFFER
SHOULD BE DISTURBED AS LITTLE AS POSSIBLE. LIMBING AND TOPPING OF
TREES TO MAINTAIN VIEW CORRIDORS IS ACCEPTABLE; HOWEVER, NO
TRIMMING DEBRIS OR ANY OTHER DEBRIS SHOULD BE PLACED ON THE STEEP
SLOPE OR AT THE TOP OF THE STEEP SLOPE.
24.) BECAUSE OF THE PAST DISTURBANCES TO THE SLOPE ON THE SOUTH
PORTION OF THE SLOPE BELOW THE SUBJECT PROPERTY, THESE SLOPE
AREAS ARE SUSCEPTIBLE TO BEING OVERGROWN WITH BLACKBERRIES.
BLACKBERRIES SHOULD BE PREVENTED FROM TAKING OVER THE SLOPE AS
THEY HAVE POOR ROOT STRENGTH AND POOR WATER RETENTION IN THE
WINTERTIME.
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PERMIT # BID
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''•f �• JEFFERSON COUNTYf 0 6 0 4 i 8
''. . DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street• Port To senld•W 883
�'�+ • JEFFERSON COUNTY DCP
.4,. .. • 360/379-4450.360/379-4461 Fax
httpJMiww.00.]efferson.wa.ue/cornmdavelopmentl.
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
I ,* — 9 t Ppoa_CIIAPPIJI:ANY NNW 1)1) &
please answer all of the following questions to the best of your ability. Where the.question oaks 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 stonnNater site plan map.
Protect Overview •
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed knprovemenls on the
site map.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the aka map.
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3. Describe tthe.exdsting vegetation. Indicate native vegetation areas on the site map.
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4. Describe thf existing spits. Indicate soil type on thq site map. ,
5, Describe the'vesting site hydrology(I.e.,drainage;behavior of ureter on the site—Above,below,and on the ground). Indicate
existing stor meter drainage to and from the site on the site map- Depict separate drainage basins on the she map, If
applicable,and Indicate aoreege of each. ,
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a, Deaodbe any excess levels off notes generated by the proposed use or aot vtty.
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STORM WATER PLAN -`
AUG 3 0 2006
Stormwa r '
mane" ..MeO"w"ingte-rev'tortnooa Require JEFFERS UNT e
DEPT.OF ' 'I Y •• .L MEN
SIGNATURE'.
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7. Desorlhe dp1Mlcant geographic features aid o8tlo81 areas (La, environmentally sensitive areas such as wetlands, strew
steep slopes,etc.)on the site. Indicate location on the sits map.
Si p p t i,ri
8. Desoto the gerwrtd vldnity of the site,Including adjaoent land uses and structures,ulpitfes,roads,and sensitive/critical are
(streams,wetlands,Wham,steep slopes,etc).
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Permanent storm ter Control Plan
This poreon of the Stonnwaterr Sib Plan contests of the selection and installation.of.the appropriate etormwater control BM
and facilities to remain in pleas after oonstructlon of the project is completed.
1'M.dlutd'sire projects are required to have the toads ordouh8ed of atl tmpervfous surfaces,pollution-generating hnpervio
surfaces, and pollution-generating pervious sudaoos to verify that the thresholds for treatment facilities and flow coil
taolilUes are not exceeded.
Descrbe the
g. in Manual)or, not,what typest rr hyckoiogy,as proposed.
kw control utilizedthe whether stormwater�rspecificdispersed
thresholld dissccharge are
• within the site. Locate these**lee
{ on the site plan and differentlete proposed facilities from existing fadhities.
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10. if the project requires the use of stomnwater buenent facilities,describe the types of stormwater treatment facilities pmpoei
for use on the site. Locate these facilities on the she plan and dfffersrntlate proposed fool ltles from existing facilities. [This
norms*for large"projects or projects that Involve the potential for dispersion ofoontaminants.)
�',.. ./f':3
f f. DeeCribe the pwformenae goals and standard,►applk*bl*to the protect.
PERMIT # r
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12. Describe the flow control system.
•
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AUG-30-2006 11 :59 AM ARBORVIEW 3602976801 P. 05
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18- Des the water quality system.
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14. Deeabe the oonvsysrros system analysis and design.
15. Describe the source of flit materiel,physical was of ON material,and deposition of a coeN material.
ffiiet
16. Proposed methods of placement and compaction consistent with the applicable standards on Appandbc Chapter 33 of the
Urnn Building Code. - _
17. Describe the propa.ed surfacing .
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18. Describe methods for restoration qf the site.
19. An operation and MeliMeraanoe Manuel is required for each flow control and treatment facility. [This is normally required for
large"projects only and only those for which facilities ere required to control flow or treat runoff:) If Included,list the Manuals
here.
20. t..ist firemany,. . . . . or studies conducted to prepare the&ormweeter Cite Plan.
21. List other nsosssary 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 hers.
sin
_ _ J--6 — 04 8
. et plan,.eV — .,0/„ e JEFFERSON COUNTY
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• •
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Conekuolon SWPPP addresses sediment end erosion oontroi during oonsinsotion. The BMPe indicated by the applicant In the
template preventinggssediment impacts followe must be Metaled onto en*onmenta ground ly seni el lity.areas a areas. Consult phases of the project. me proponent is responsible Connstruc$on Stonnwa$
Pollution Ptsventto (SWPP) Beet Management Predicate (IMPS) Packet for guidance, particularly with rural reeiden al
development.
fleCTIONITAXINSTRMION SWPPP NARRATIVE
1. Co+Wnation BtRNmwwIsr Potation Men Elements. Describe how eaoh of the Construotton SWPPP elements has been or
will be addressed. Idenaly the bye and location of WAN used to wifely the required element. If en element is not applicable
to the proposal,justify In wiling. Descriptions of the 12 Elements are found et motion 2.5.2 of the Manual(baginning on page
2-15).
12 Requited Elements—Construction SWPPP
1. Mark Clearing limits.
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2. Est bteh Constnuotlon Acmes.
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3. Control Flow Rates.
4. Install Bed1ment Controls.
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5. Maize Solis. v
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Ck 5 r,; p r S 4-LA S`.-e..a ", `,Rr .1 at oi'g o r s r"AS2a, ° h n
7. Prolsot Drain Inlets.
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12 Rem,Sid Semen*—Construction 8WPf P econtinusd)
8. Stabilize Charnels and Ouuets.
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A. Control P� .
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♦:a '� 1S S.1 �a.�l`� �O'� C'A�1� ti.\'�.+:..'�`��'' Y"�v^ �'dY�-:"Gr u r'�l�l�ti .1SLA', f q S
044 •( i-.'^"i1 V•i Cf r v^ a(2�.Lp,...r,i,:..l - -
10. Control De.Watedng(the act of pumping groundwwder or Momrmttsr away from an active construction site).
11. Maintain Bost Management Preolbes(BIIAPs).
12. the Prmmeat
J
2. Adjacent Areas.
a. Description of the adjacent areas that may be affeclled by site dlsturbanoe (e.g., strewm lakes, wetlands, residential
arena,roads).
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b. Description of the dawnetree m dratnawe path leading from the site to the receiving body of water(minimum diatoms of 400
yards).
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8. Environmentally Samlthre Areas.
,a, Description of areas thatgns on or ad14cent to the site.
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JEFFERSON COUNTY DC
AUG-30-2006 12 :01 PM ARBORVIEW 3602976801 P
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b. Description of special requirements for worldng in or near environmentally sensitive areas.
4. Erosion Problem Are... Deocifption of potential erosion problems on site In the oonteoct of the oharaotedetios of the Mate
was(o. , ocitbilty►,eattiabillty.permeability.depth,teodure,soN structure).
M/ er4
6. Con.truo11on Pha.lrrg.
a. Construction sequence
b. Construction phasing(If proposed)
�. Construction Schedule. Wet season is October 1 trough Aprti 30(paps 2-21 of the Manual).
1. Provide a proposed construction schedule. - \
l.l)' 1 c cry, 1 b q, ,n r, n 4-Las. �.Nc r_�v s,�.`a� s y a c S b9�p y S P�r rn i"b,
11. Wet Season Construction AotivNles.
r a. Proposed wet season construction activities.
b. Proposed wet season construction aaUvities for environmentally esnaltive areas.
7. t hip Responslbtttl.s.
a. Identify the property owner responsible for tine irnitiflon of bonds andlorother financial securities.
b. Describe bonds andfor other evkbnoe of finanoial responsibility for liability associated with erosion and cementation
Impacts.
& Engineering Calculation.. Provide Design COICU110011.on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Dlventione. ..
c. Waterways.
Runoff/8tormwatar Detention Calculations ,se-CL S tc3 rto► war CpEptiff # s y,]„ F
00 - 04I0
Bloarmittst rev 1 JEFFERSON COUNTY QCU '�
HUIa-StO-GbfDb 1G b1 rri HKiiVKV1tW 36029765301 P_ 09
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Stonnwatlar Sits Plan Changes
If the designer wishes to make changes or revisions to the(riginay approved Stormvwater Sae Plan,the proposed revisions shah bs submitted to OCO peter to oonshucdon. The submittal shoe include substitute pages that Include all proposed change., revised
drawings showing any strut:Wm!changes,and any other supporting lamination that explains and supports the reason for the change.
Final Corrected Plan Submittal
if the project Included coneituotion of conveyance systems,treatment feoli iae,flow control Willies,or etuctural source control Sties
(not standard on-site slorrr+vrater management BUP.),the applicant strap submit a final corrected plan(ems-buNa)when the
oee .These should be engin..rtng drawings (stamped by a licensed GM engineer)that accurately r�eprm er>t the pro4 ofeotes
APPLICANT SIGNATURE
By� g the t uc ton SWPPP worksheet, I as the applcanVowner attest that the Information provided herein Is true and
carted ers to the
beg of my knowledge. I oleo cattily that this application is being made with the full knowledge and consent of al
properly.
i ce {1 7 ° ®a
Q Orr AUr GRIND trearereirtr NE sporAtuns)
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THIS SPACE MAY BE USED FOR ADCNT10N I.,NOTES,IF NEEDED:
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4,ir.v.SON co JEFFERS COUNTY
1� 4 .; DEPARTMENT OF COMMUNITY DEVELOPMENT i ECLi 1Y ED
r" 621 Sheridan Street • Port Townsend • Washington 98368
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Master Permit Application # � - T�»
Project Description (include separate sheets as necessary): ANON it-- I 1
r>rr &v" i- R+^s%\1 e12. 1 NC ne e. t. I (h i U Cr0•- t C4 CA r 3,j On el C- 0 c ei e,. �'- t,�r A c7.G ry,"I eA i-, k
J Property
Tax Parcel Number: 1 5C 1 0 13 I + c 5(U 1 0 i A r .,)- Size: 1 ``'1 , L) I 9 se) r-}. (acres/square feet)
Site Address and/or Directions to Property: j a C`• 1 - ) I-, :,e n (I`` i-s e. P-}, Lt.t(1\
Property Owner(s)of Record: 4y 04. L ,c, rI'0,,,i,-,a,.-
Telephone: 3 10 0 P.). Le 4; SS"2 A ) Fax: 3 c,c1 • . 9`?- Cn Se0 i email: (,4-ci`;:_wl Q, C I e 1ca1 r . tl;,
Mailing Address: P CI, AC,-)i ,_; r k t rrni-1-o, LJ3A 1t A;I V
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit? (Check each box that applies)
0 Building ❑ Variance(Minor, Major or Reasonable Economic Use)
0 Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
><Single Fa ❑ Discretionary"D"or Unnamed Use Classification
g Garage Attached Detached ❑ Special Use(Essential Public Facilities)**
C1 Manufact d Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
I l Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
X 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
0 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: �ji/ (�"
Date: /�`�
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this 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 respo .bility for adhering to and mplying with the ESA. The Applicant has read this disclaimer an
d signs and dates it below.
Signature: i .�1•!'�/r►.T�, _ Date: rOv
f�
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 assumin the resspp sibility oft e General Contractor for the proposed project.
Signature: si -" . rp ,erf,,I/ 1 - -- Date: /7�/f/0G
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: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
X1 New Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank Height: ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: .5 ' Individual System
❑ Repair ❑ Masonry SEP Permit#.` Od..),(o ,),
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well ❑ Two Party
Type of Heat: Proposed: .'Z -$i Public
/-:^J�(fn 2 „t„ r/e:cle c Total: , Name,pf System:
/R st.;-nc'ico:*-.s 4'rC jr 4 4 L)( T f2`/-vpti 44
If this is a Commercial Project you must answer the following: 1/
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants (includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
Li Underground Tank A Above ground Tank Size of Propane Tank: >;-)0
X Heat Stove ❑ Cook Stove 11 Woodstove I I Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove i i Other lr�nkle c
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No Li `ct't.„ h'k,.A'�r
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated 101.131•`o EH Bld App Review:%/3 op
2' Floor Heated / 5—, '4•b8 Consistency Review: co
6 54 I3
Other Heated Base fee: 13910 •�5
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
50
Other Unheated 2 5 z gitS.24 Pot Water Review fee:
D 0 rci()4'-- q0 .61)
Garage/Carport 2 (o$j 1.13 SUBTOTAL
Decks 2 v r �`� — 'I" $yBSZ 911/Rd Approach fee: 0 K'`�
Other� 1 A44g7 TOTAL: $070( r►
Receipt Number: .v 53/i''
Cash/Check Number:
-_ i
ESTIMATED COST(REQUIRED) ('1 lq ID Date:
•Fair market value of all labor and materials foundafo u finis
Initials:
1 I30, oc)C) -
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc