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HomeMy WebLinkAboutBLD2006-00447 •BUILDING PERMIT APPLICATIUN M ReviewT0435 Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00447 Received Date: 8/2/2006 SITE ADDRESS: 2452 OAK BAY RD PORT HADLOCK, 98339 OWNER: RICHARD CICCARONE PHONE: 973-383-7928 KAREN CICCARONE 8 FREDON MARKSBORO RD NEWTON NJ 078605009 OAK RIDGE SHORT PLAT SUBDIVISION: Block: Lot: 2 PARCEL NUMBER: 921182031 Section: 18 Township: 29 N Range: 01 E CONTRACTOR: WALTENBAUGH CONSTRUCTION CO PHONE: (360)385-6105 40-A SETON RD PORT TOWNSEND WA 98368 Contractor's License WALTECC012BA Expires 1/1/2008 REPRESENTATIVE: WALTENBAUGH CONSTRUCTION CO INC PHONE: (360) 385-6105 355 LOFTUS RD PORT TOWNSEND WA 98368 PROJECT DESCRIPTION NSFR W/ BREEZEWAY & ATT GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,032 VALUATION 550,000.00 ADD'L: 760 HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: #OF STORIES: OCCUPANCY: CONST TYPE: 5N OTHER: 140 SHORELINE: CONST TYPE: GARAGE: 576 SETBACK: DECK: 205 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 3 Total: 3 Total: 3 Routing ate: 12 Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $3,471.25 LYK 08/02/06 83933 Plan Check $2,256.31 LYK 08/02/06 83933 State Building Code $4.50 LYK 08/02/06 83933 SE.' II 2006 Potable Water Application $55.00 LYK 08/02/06 83933 Jefferson County Planning Total: $5,787.06 & Building Department BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00447 Received Date 08/2/2006 SITE ADDRESS: 2388 OAK BAY RD Issue Date 09/11/2006 PORT HADLOCK, 98339 APPLICANT: RICHARD CICCARONE PHONE: 973-383-7928 KAREN CICCARONE 8 FREDON MARKSBORO RD NEWTON NJ 078605009 SUBDIVISION: OAK RIDGE SHORT PLAT Block: Lot: 2+ PARCEL NUMBER: 921182031 Section: 18 Township: 29 N Range: 01 E CONTRACTOR: WALTENBAUGH CONSTRUCTION CO PHONE: (360)385-6105 40-A SETON RD PORT TOWNSEND WA 98368 Contractor's License: WALTECC012BA Expires: 01/01/2008 PROJECT DESCRIPTION: NSFR W/ BREEZEWAY &ATT GARAGE CALL IN FOR THE REQUIRED INSPEC I NS THAT APPLY TO YOUR PROJECT. SETBACKS: LW/O// O(, UFFER: i 11FF,E 1SK /40104# Footing: IJ/( /04, #,/ Foundation: D1( ///3/4,L, Stormwater FINAL Approval: Underground Plumbing: Underground Insulation: Shear Wall : k-xr 5NEAez.di4c JA/u1vt 4 ST,e. OK z/5/47, ttetA.,Au-S i rl.015etc 2(-o7Ld Sheathing: Framing: Lf/koA /z/J/oh 'II`-ti,-7AV-/U 7 ...)t[,c7 . Die 31 4/67 Plumbing: :-)u Div' cAc 7 t-o 7 ,4T t Propane Tank/ Lines: Insulation: A,,%,25r19c, or_ -4 l (-67 !J/fa-s 4(I,QLLnfb e4"-k/iuGs DK 3/4/6f Sheetrock:04//0/b &4utrE, 1 u io ?e SE i) Septic Sytem Final App oval UST be obtained before final o structure can be attempted. Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: 6 K- fiat_ C4-e-wZO(4 (t). L7-p " 1, HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. HOT LINE AVAILABLE 24 HOURS A DAY o SPECIAL CONDITIONS APPLY -SEE REVERSE f Verb l�I¢2A koas fAisia1ibD( i'/9) 3/q/07, • SPECIAL CONDITIONS FOR CASE A BLD06-00447 • 1.) BEFORE INSTALLING RETAINING WALL ALONG DRIVEWAY, BRING RET. WALL SPECIFICATIONS TO BLDG DEPT FOR STAFF TO DETERMINE IF PERMIT WILL BE REQUIRED 2.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 3.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 4.) Prior to and during approved construction activities, the perimeter of the landslide hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 5.) All construction activities shall not encroach upon the landslide hazard area buffer. 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.) 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. 8.) VOLUNTARY MEASURES OF COASTAL &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. 9.) 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. 10.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). • 11.) The project shall comply with Construction Stormwater Pollution Prevention (S PP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 12.) A Stormwater Site Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 14.) Not more than 2 unlicensed 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 autormobile 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 requriements 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.) Minimum setback from the private ingress/egress easement right-of-way shall be 5 feet due to the easement dead-ends on this lot. (The Development Services Manager, Stacie Hoskins has granted this reduction based on JCC Table 6-1 that this portion of the easement is more of a driveway to this lot since it dead-ends on it) . Minimum south property line setback shall be 60 feet from the adjacent rural forest lands. Minimum west property line setback to the structure shall be 45 feet from the commercial forest lands. Minimum east property line setback shall be 30 feet from the landslide hazard area. Minimum north property line setback shall be 20 feet as there is an existing 20 foot wide platted utility easement. 16.) 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. 17.) 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. 18.) The building height is not to exceed 35 feet. 19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 20.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. I:\F_BLD_Permit_Buildng.rpt 10/29/1999 PERMIT # S 0 6 - 04RED4 7 RECEIVED e �� JEFFERSON COUNTY°R( A J P 1U iTv ,,, 4t.3 DEPARTMENT OF COMMUNITY'DEVELOPMENT t DC[� f �1 621 Sheridan Street-Port Townsend •Washington 98368 t C h �,Ot NTY ,• 360/379-4450 •360/379-4451 Fax LI �l(� �; I C; O� http://www.co.Jefferson.wa.us/Commdevelopmertt/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE � f MLA# -Ll PROJECTIAPPUC4NT NAME: Pi l inkvA �.{tee r, (7,tC ctz. s._.kl1 Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate stormwater site plan map. Project Overview 1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the site m Nj r. ti..rr 1 (,000a fr-tulAzii si OP2 fii3Otiiii Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. —UM 1� 1V ' iL 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. [16:+OA> 'irlitate-y\ 4. Describe the existing soils. Indicate soil type on the site map. _`_ t, fo14, 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. Wilk- ! tW►b411- . - 6. Describe an1 excess levels of noise generated by the proposed use or activity: - APPROVED STUKMWATER PLAN SEP - 7 2006 stormvrater site plan template.doc—rev.10/12/2003 Storfri Ytlaj� 's \ ,` 5 Required ' IEFF= CO N Y� Q DEPT.OF '1 D: E OPMF SIGNATUR • • PERMIT # Bill 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as welhnds, streams, steep slopes,etc.)on the site. Indicate location on the site n np. Q 7 JEFFER COUNTY PCD 8. Describe the general vicinity of the site,including adjacent kind uses and structures,utilities,roads,and sensitive/critical areas (streams,wetlands,lakes,steep slopes,etc.). - Permanent Stormwater Control Plan This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs and facilities to remain in place after construction of the project is completed. °Medium" size projects are required to have the totals cal, lated of all impervious surfaces, pollution-generating impervious surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control facilities are not exceeded. g. Describe the developed site hydrology,as proposed. Indicate whether stormwater will be fully dispersed(i.e., per BMP T5.30 in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. ` bI Nv[ta `Y &d ' h6ottorkg/i Ifysed 10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is normally for'large"projects or projects that involve the potential for dispersion of contaminants.] 11. Describe the performance goals and standards applicable to the project. S ii'12 I G�/Yl t. a Skftie- i C624wc_. c_e 12. Describe the flow control system. kl/P 6 stormwater site plan template.doc—rev.10112/2003 ` F 1i3`S+ • • PERMIT # BID 13. Describe the water quality system. 0 6 - 0 4 4 7 'Ltd ► ' �' JEFFERSON COUNTY DCD 14. Describe the conveyance system analysis and design. 'v 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. Arannirgivi t 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. b&c4LU of ilk C' ct k tut.Avu 42471-tfA) Y'tC.c 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. 1\ilk 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. J\JU- 21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or restrictions here. it\ - i.; ECEIVED 7 stanwater site plan template doc—rev.10n2c003 JERBSUN CHO ON ill 'ERMIT # B!D CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) 0 4 4 7 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$WPPP NARRATIVE 1. Construction Stomnwater 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 ClearingLimits. 2. Establish Construction AcrpS5. c try ,t,) 3. Control Flow Rates. 4. Install Sediment Controls. . hAN:'�1�1�TIVIII.���1.P� 'LT�7MIleg �iL1 It/./li�Ll�:.��a� �iL���/ • j* .+t ..f,a l'WVSIi�irt..�2;wh . A r ,,Z, rJRMII r� _ ,IL . 5. Stab ize Soils. disrzwei im Airtio_ktritl 6. Protect Slopes. JJ1c 7. Protect Drain Inlets. kJIbt RED'EI_\TE! )) 8 abnmwab.ode plan template_doc—rev.10/122003 {} rr rr Irk[\i f,(y`t Il�fl i!Ij�'(�il jFF ERSON COtiN11 liCP . • PERMIT # BM 12 Required Elements—Construction SWPPP(continued) 0 " 0 4 4 7 8. Stabilize Channels and Outlets. J.EFrEBSON COIIN IC� 1Y D CO 9. Control Pollutants.1 wt 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. 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). tiedi , (IA -- wt,r 4,4 411i/4 be_ ,f..-Aztt, b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). ,�1��/�� s tL f. ,l/p�e-L s Wth.r 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. �.\ tl n��•_ A It. kcf l-1 9 ` stormwater site plan template.doc—rev.10/12/2003 1MittiSliN !AUNTY i r • PERMIT # BLD 00 -- 0447 b. Description of special requirements for working in or near environmentally sensitive areas. fFE R S 0 N COUNTY C D I . N Pi 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure).- 5. Construction Phasing. a. Construction sequence i r \P( b. Constro7 phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. P vide a proposed constru ' n schedu�le. II. Wet Season Construction Activities. a Prnnn.d+we+ea.2 nn r nstrudion activities. . b. Proposed we season donstru Lion activities for environmentally sensitive areas. td Pc 7. Financial/Ownership Responsibilities. a. Identify property owner responsible for the initiation of bonds and/or other financial securities. ,q; b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts, IvliA 8. Engineering Calculations. Provide n Calculations c n a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. t c c. Waterways. t c d. Runoff/Stormwater Detention Calculations 1y 113( 10 stormiater site plan template.doc—rev.101122003 a *PERMIT # RED 0 6 - 0 4 4 7 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 indude substitute pages that indude 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 proved 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 Construcion SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and correct to*he 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. /+ (I AUTHORIZED REPRESENT (CIA 111RE) n L (CIA THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: • i - abn,saty,site plan template.doc-rev.10/122003 12 HUU-112-, 2ViAb, 11:1ti NEW I UN FILM 1 NF'H I t EN I MH P.01/01 co JEFFERSON COUNTY �""�. 4 DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street• Port Townsend•Washington 98388 iliziAN cEi , #pir 4.!.. V {� 360(379-4450. 360/379�1451 Fax $' � $ wvwv.co.jelferson.wa.us/commclevelopment JEFFERSON pr(Njy n� , Master Permit Application MLA: X `42 Project Description(include.separate sheets nocessa ): _ ,) _, ��itj P,>rsrr ttic ,u>1,t,taxi5vy►�tfp fir, Tax Parcel Property Number ei a4 i v 031 _ Size: 1.1 eiert9( 7 4,�b1A ft acres/square feet) Site Address and/or Directions to Property: 5 f J,�/L q g�3t� Property Owner(s)of Record: Telephone: It- Far lt- Malting Address: r era 0 _ `l`d D- b • Applicant/Agent(if different from owner): and" �l4'1G Telephone: = � i5.-I c!1J J Fax -3 - email: Df at/t Mailing Address:4I-A P 1.- 6 g. ,yYhat kind of Permit?(Check each box that applies)Building L lVariance(Minor,Major or Reasonable Economic Use) d Demolltlon Permit ❑Conditional Use(C(a),C(d),or CI"• e Fam ly °Discretionary'D'or Unnamed Use Classification ahtge Detached Dspectal Use(Essential Public Facilities)" 'b Manufa a DBoundary Lime Adjustment D Bdodular DShort Plat'" Commercial• ❑Binding Site Plan`• CI Change of Use Ot_,on9 Plat". ADy Address 1 Road Approach ( Planned Rural Residential Development(PRRA rnendmentc"" Propane DPIat Vacation/Alteration"* DAilowed"Yes'Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions" OStomtwater Management ❑Shorelne Management Substantial Development" Mite Plan Approval Advance Determination(SPAAD)• °Shoreline Management Variance OTemporary Use OComprtehensive PlanluDClland Use District Map Amendment [Wireless Telecommunication• L°Jefferson County Shoreline Master Program Amendment ()Forest Practices Act/Release of Six-Year Moratorium •Mayregvate a Pre—Applicarrmr Conference "Regains a Pn:-Ailpflcadon Conference Please identify any other local,state or federal permits required for this proposal,if known: I hereby designate ( FAIGNATION OFAGENT /• .,to act as my agent in matters relating to this application for pemik(s). Sr JER GUAtURE i� /. -.. t�.r�yt-'L-_ Date: d�cZ/O }o By signing th•is application form,the owner regent attests Chet the Information provided heroin,and in any attachments,is true and cared to the but of his,her Or It's k!aow edge. Any material falsehood or any omission of a material fact made try the ovmeyigent with rasped to this application t>Acket may result In this permit balnp null and void. I further agree b cave,livemnlry and hold harmless Jefferson County against all trablHfiea,Judgments,court coat8,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 10 provide access and right of°nary to Jefferson County and Rs employees,representaeveep or age for the sole purpose of applcaton review and any required later inspections. Staffs access and right of entry will be Sasurned unless the applicant informs the County In writing at the �� time of the applcation that ha or she wants prior meta Signatire_�r C he�c Orate. �J/0 The action or actiona Applicant will undertake as a re suit of the issuance of Pile 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 we defined In the federal taw known as the 'Endangered Species Act'or'ESA.•Jeffers,,..�eun f assurances r makes no assunces to the applicant that the actions that will be undertaken because this permit has been issued writ not violate the ESA. Any individuei,group or agency can file a lawsuit on belief of an endangered species regardingyour aellon(s)even if you are In compliance with the Jefferson County development coda.The Applicant acknowledges that he,she or It holds individual and non-transferable respaneibiily for adhering to and complying with the ESA. The Applicant has reed this discialw and signs and dates it below. Signature: Date: •!r x/� !/ a \Premireunte\POAMS\DID FORMS\Mince Permit Appli eon 12-30-05.2.doc TOTAL P.01 • • BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: W& ) . Co TA/K., % ) - YES-�i/Q,5� ( ) 314- t i31 MAILING ADDRESS: .� a�A"/t k po.,„ -rwyl OA EMAIL: 14)60i ivy. CONTRACTOR'S LICENSE WAINS U NUMBER: War-tp f�, ,o 1� NUMBER bet14i 031 ARCHITECT/ENGINEER: `�CJ PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New Ii. Wood Existing: 0 Sewer Addition ❑ Steel Proposed: _ 3 _ Bank 0 Community System 0 Alteration/Remodel 0 Concrete Total: 3, Height: `±,1 Individual System 0 Repair ❑ Masonry SEP Permit#_`-C-PD - Ju1n- ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: 0 Private well 0 Two Party Type of Heat: Proposed: 3 P.Public ‘2.0dt-ty - Total: 3 Name of System: ��. - ❑ If this is a Commercial Project you must answer the following: �ff Number of Parking Spaces: Current: Proposed: ►V 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 0 Above ground Tank Size of Propane Tank: °Heat Stove 0 Cook Stove 0 Woodstove ❑Fireplace Insert ID Hot Water Tank 0 Pellet Stove p 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. , y�� r 2 .,,�:�1I31'S�UAtik <' ''7n +it' •tier.. Square Footage Current Proposed �r,�tfftoe.jlse,4n1y - .: .... may=��, Main Floor Heated /I��hh * n1 EH Bid App Review: // 2n0 Floor Heated ` `# ' Consistency Review: 5 cp -Tteo 1,,.1 )gu I 3 Other Heated Base fee: '7�,1.--, Mezzanine Additional Section: Heated Basement - Plan Check fee: Unheated Basement . State Surcharge fee: Other Unheatedar� j O Pot Water Review fee: q b pO Garage/Carport 15 "� SUBTOTAL b�O ;: —► G ecks 1 • 911/Rd Approach fee: n, JJ 0 t4 r z8 2o:; Cx t ST) W, the tel ):CA20(,S TOTAL: $l GQ C) 1.Q ) Receipt Number: Z3CiL33 Cash/Check Number: ESTI 1' D COST1REQtRED) Date: l�(o • rket value o or an materials foundation to finish U n®b y Initials: rl� i D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc C 1'T v� P T O Z g � Z � O G v CO / CT) its) r 61 �= a s e vi e Tn-1 40 1 AsT • _ �Zo s ��,=D T� ,,- A ore N�If 0 2a OTC ker5, load( 5 rriA�� may. 0 _ v JEFFERSON COUNTY IC[l • r t O;IY>i �, DI • 1gv�+�rtt R.OI -MP IC ;Sin! Fau ISoe Gar LL7p` Joh g i j LAt ? !. 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