Loading...
HomeMy WebLinkAboutBLD2006-0456 RILDING PERMIT APPLICATItN MLA06-00448 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00456 Received Date: 8/7/2006 SITE ADDRESS: 10232 RHODY DR CHIMACUM, 98325 OWNER: ROGER N BOTNEN PHONE: 360-385-0232 PAMELA BOTNEN 10234 RHODY DR CHIMACUM WA 983258709 SUBDIVISION: Block: Lot: TX46-i PARCEL NUMBER: 901112032 Section: 11 Township: 29 N Range: 01 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI DEMO EXIST M/H TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP DEM MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: 2 Exist: 1 Prop: 0 Prop: 0 Total: 2 Total: 1 Routing Dat : cJao Type Amount Paid By: Date: Receipt: Approved/Date` Er Permit $51.00 LYK 08/07/06 8:3940 Li State Building Code $4.50 LYK 08/07/06 8:3940 SEP 0 2006 Total: $55.50 Jefferson County Plannin & Building Department • • DEMOLITION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00456 Received Date 8/7/2006 SITE ADDRESS: 10232 RHODY DR Issue Date 9/6/2006 CHIMACUM, 98325 APPLICANT: ROGER N BOTNEN PHONE: 360-385-0232 PAMELA BOTNEN 10234 RHODY DR CHIMACUM WA 983258709 TX46-i SUBDIVISION: Block: Lot: PARCEL NUMBER: 901112032 Section: 11 Township: 29N Range: 01W CONTRACTOR: OWNER/BUILDER PHONE: OWNER, ROGER N BOTNEN PHONE: 360-385-0232 if different: PAMELA BOTNEN 10234 RHODY DR CHIMACUM WA 983258709 PROJECT DESCRIPTION: DEMO EXIST M/H 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 9/6/2007. REQUIRED INSPECTION: FinalApproval: , 61"C—V7 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 • • SPECIAL CONDITIONS FOR CASE#BLD06-00456: 1.) The application was reviewed by the Jefferson County Department of Community Development staff on August 22, 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: conservancy shoreline designation; Type 1 stream; Fish &Wildlife (pacific lamprey); seismic; flood; SARPA& SUSC aquifer recharge area. 2.) 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. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 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.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 6.) A Type 1 Stream (Fish and Wildlife Habitat Area) has been identified on the subject property. The stream will require a setback of 150-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 7.) Stream buffers are areas that 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. 8.) 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). 9.) The project components are more than 250'from the mapped/identified wetland. The requirement for a wetland delineation and report is waived based on maintenance of a 225' buffer from the wetland per UDC Table 3-3. • • 10.) The project is located in close proximity to an identified wetland and is subject to the delineation provisions of Section 3.6.9 of the Jefferson County Unified Development Code. Based upon the proposed location of the project in relation to the identified wetland, the applicant has agreed to maintain a buffer(setback)that exceeds the standard buffer requirements by fifty (50) percent. The applicant acknowledges the additional setback and agrees to maintain the extra 50 percent buffer, therefore, waiving the wetland delineation requirements of the Unified Development Code. 11.) 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. 12.) An additional setback of five (5)feet is required from the edge of the stream buffer area to the proposed mobile home. 13.) The applicant is proposing to create or add 784 square feet of impervious surface and 784 square feet of land disturbing activities. 14.) 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. 15.) 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). 16.) The site plan as submitted with the mobile home installation application on August 7, 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 August 22, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 17.) This approval is for a mobile home replacement& demolition of existing 10 foot by 50 foot mobile 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. 18.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 19.) 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. 20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 21.) Minimum setback from Rhody Drive right-of-way shall be 35 feet. Minimum side (north and south) property line setbacks shall be 5 feet. Minimum rear(east)setback shall be 1275 feet per submitted site plan. 22.) 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. 23.) 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. 24.) The building height is not to exceed 35 feet. 25.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 26.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 08 3E1241rab 05:38 3E04171,1E7 PAGE 02 04. 10 2008 12:2.8 FAX 3C0 111E37fi ORCAA • CJ001 • RECENED AUG 1 0 200E icuazJ a PERMIT# -F ) .APPROVED ` y�$� ORCM � f„� CONDITIONALLY APPROVED NOT APPROVED RCA FOR COMPLIANCE WITH oo rair +�nn,e..�u� ORCAA REGULATION 1 J Notification of Demolition Permit it is anlawfirl for any person to cause cr allow the demolition(or major renovation)of any structure■ales 111 asbestos. containing materials have been removed from the area to be demnolished_ Work shall not commence on as asbestos project or demolition unless the owner or operator has obtained written approval from ORCAA. A written application far a demolition shall include a certMcatioa that trine is no knows asbestos-eontaining material remaining in the area of the structure. • Project Site Address: I f `9- 9-, KhOCuA,Uk I UPS _county:JLrS OY) City: rna_ ryi.. State: A zip: 9 k. c Starting Date: _Se,✓ OT d O Completion Date: _____ O Q{v (There is a 10 working day advancenoti cation period from receipt of permit applcation) 'Thhoc-sec^i Property Owner -e!Y14 Y\ Telephone: C,0"?-) e.), `5 .Fax: n i .5 2 lUlailin Address: I0,9„;41- k to ct-(j- Q k f-cR Q. City`. h ono G-C-L t!Y1 State:_ GAJ DR Zip: 2C Demolition Contractor: P�'.i')Gil k n b State License.#: l�Qailiri Address: _ City: .__State: Zip: Contact Person: Telephone: - -- Fax.: YES NO Demolition by Wrecking or Disotantiing? ($25.00 fee)check Training Fire Demolition? (If yes,attach fire department request for training tire) X &eraovaiion,Alteration,Remodeling,Maintenance,or. other Construction? _ Asbestos found or suspected* *An ORCAA"Notice of Intent to RRurnve or. Encapsulate AA:waveform end appropriate i}c rnust be submitted prioito any asbestos removal wo& Asbestos remora!p'oj.cts involving demolition must be prafprmp4 by a Caiifted Asbestos Contractor and all ftisbio or potentially friable asbestos must be removed before any demolition begins. Refer to ORCAP. Replatioe 1 Article 14 for additional ;equirensent That may apply. Asbestos Survey Completed by Aff ET,iA Certified Xuspector E© hram, L l ' 1�1' I_ Certification#_ I C7II j/ +`.- This approved permit must Enclose$25 Certification of the Asbestos Survey crust be available at the job site Processing Tee accompany sus form WO:. A 2940 B Limited Lane NW,Olympia,Washington 48SO2 360-586-1044 • SOO422-503 " fax 360-491-630S rtino2 �i z mvpaga www.otvaa.org* email;infotaioresa.org crgt --i a ii• �,; E,,`<<dh I,y: , c,a:l'iat„ PATE ��_ 05i 0,2Ui)f3 U9:.G FAX •:ftiG E1tly ORCAA • 1i1111 AUG-30-06 1e :Z4 PM JERK'?: InIT 54r a85 2383 F'. Eil > c��Inlctal et,ION ctt �_• Date AP lies Arm:mill, CI_ ti'p,g' - 0,, ' �, 2040 B Limited Lone NW �.'��� t~` ,.J N,% Olympia, WA B 5OZ � ,�., .a �. compk.iEN,:Cl_____ . �►1- Phone:(38a)535.1044 n 16 "-.ORGA4,i' Fax:(360)4914300 4itt ,Annual: $500 vohoer.?;ECAA„arg t Permit Application for an Asbestos Project AFrroit t,T tc !.Y,1�7, coo4 R0< 2.D kerrorst on ! 3 C] Mr;nrfn',ca- ---- ___ w- V Demolition r 4�E:lictms r j p• 6.EX Emerged J 7.Q 0-71 r. --___-._ 0, �wner• r— ____ ,p pft � 6oi-neri . Phonr:51:�.Jti ag5d i Property.Owner e Lipilineddreee! )on..3 _ riklo t�.• O 1 City:0 VIt rYld f(OK st ta:,iij TZ. 1 C, MbestosCotttractora "�� {{, C t�letor Owner/CE `rota?I!,ag,nnQt _ __.,. Phosit:i ei, �) , i p, air Adimlj. ---1---- — ' ... C)W2- • '•,0_G F- k ! CFty: 3!r Y . C et rri I State; Wft i.ZioVN iProject Manner or ,r- 1 Contact laol_rear 1-'(7 rat Ica.,_ Y G Aa,m JE.'A.hettesBurn or ?tie.ofStructur e;: r I Ph�ttc:,, ),}� ,I 0 SUN Prewameci; f i Nita AsbestoB SWtioy Conducted; I Waurlltbcstos Found? _..__...._ ___.__ I -7"- `I' 0 lrlvo Attach ltnn;L_� AHERA t?e!ilduig f7,111AI",;Ai► ITti peUkai..T"ASAld.PRAfdYPan, CCs6S11cadon No,: ti ,-_ Impactor Name; _ ,R;r-vr..n. Expiration Hato: 07—KiCiltilCtims i No.off&root arm: I Start I G� Training Fire(List Fire Mot.as demoritio cs ntrector b 1ow' information; _L i Date,ii"r �"'C j 3 (3r d Etemolition(attack copy o (kiior) ,. ____I Demolition /eer MM.soy.twerri,Pig okra,a Npe JPMt4tt orkr, PRO4011g bam MN 41,-.4,--,....Le, Contrition . Phone.( ) G. Aatieartoi , No.of Strueructa:(oat 1 Soot Date! Compiotior. At.Dryas M T(w)Th F Sa Su Projem 1 back if> I) i �- Hours; t�� _a-1 -0 DI- .�-c Will an aahectu9 me x;tic rc novcd by Total Qutlnia to be Rerrroved: AV_____ &Lwur Fact Linear Feet prajoc mj poi? Yes Q No bertnel 3ymoin lnaulotion: J LIB_oiler/Furnaee ins l�Da.let Iaa 1 ❑Pipe Ina t °dun S_wceiding.Ma i _^; F. 1littP0f#,ng 1. A:r-Tt;t P,IARtCt 1 LTexhlro6Goatin a Other .._.._..._-.� _,..._,_____ a Rise.Mat is i 0 Cement i5d, I�Ceraaax Plpe T f loorina Marl Roofing Midi t7Pfiers "..... "..-_._ -ihi7 watiiituayDetd4lition Protectd�oe es: - _ Notification,waiting KrIZ p4011AFAJrt t6LPt _1, r71 id®tatiai�wetiin�Asbcatoi Rnmteral P�snpa Pour lYotic� __ Z. Darwinian — 10 Working F � '- s.z.fr 3. Qk1ththan 110 linear feet or Ierr 1 t in; _ _ Prior Notice --- S 4. u io-S.3:0 limner. e>►1T- swore feet 10 Working Days ' _ 100 , v V991Inoar".for t60-44,9p9eat f - 5�TF.., 0 999 ilncar feet or 5:0(4)-4 J le Workil+g Days _ $250 t` ' �� 9 13�Work: Dote • sSaNl 7. v1 000 i linear fGCt T a flare feet W fic _____,1,..,...„,,, - - l ll.-•Arstgatl Porrhk(I..imi rin_l l• honeJ��ortrrt O . AA) Prior to start of , e,r--1 - ' F 1uriencv,_Plvjt7et Pri ice -SSO__,,,i to,U intaua(no fee tibr iI"atd_''attwndrront) _ Pnor Notice I du hereby Wdiry that iha Intimrn,ti.s..,.tnrtiwcd in rb otlf uiloi and auppar remul au Pnynttet MINN door --45 .knathad trarvirt,M to the beat otaay know lotu s emorac end campkle, i.trot i not osneo ar al taw newer id date, ia, wttcakta P r}t LY ca d.rrw,titio9 ari vines rP ha in .zdl dta alc - . Y a avPropri tv4king poricJ tu► q ,yam) `-__ pa}rjr4, fol htYkwed bp Normal MonirtImri .�a_..j`] �R}�c `/,.77�.�_ Sian ,,( leUC:tQ ,Fr. . C,,0(e, Air!'hoed/wutlad wI11retlua Cs aPPlkani .�l i`- -- - 1 For au mpearor Riot Rt�r.Mni*sn 1,bah so t4-AA.�ew a'nin Nam�:�C�-f?�1 t(l. j 'r1 (L'� 84�rdetlntia Qif:t O _,..._....1 R' � —1 ARa'NtCY the arm,,a7ro7,04 P A 1 e:31.2)at-{ tat kJ!. CK.NO, DATE 7.2:a& -1. 2 -.1 ..... z (17 -' 7 ------- .9 > „.,... r•-•.- 1 2 y.- ., 6- a '---..'-- X7 .._ ,. -----.• .-,, , - ....... ,....._ ..,.............. , ) 1 , ',.;.S.'• 4* .,-' ------,Cov It); 't ., i , ''..-• eltvo-" , . ..„ .......-- ,.,,,,- ib. .'., ; y, 1, -,-; • _ 9).,0,,,,.,,,,,,i)ko' it., t' *.b.:1,,,,,ft."'4'le-- ......,- - \ 1 --- I ve ----- , , ..- ir .\ (,) t''' t),, 1 1%is 14;.' 31,. ...-- .- ........ ____ 't rj --- I / ,t*:,s.k‘,1 ('''''t i „.,.... - ,..... M ri t W. - re , VIC' -. •' , i , ' ' > ... : \ Ro.i v, II _..____,,.7,417,-,:_.,,..... ,-,--,,,--•lY\3±1.,..1.-_, ---..--.---. _..___ _ . ...;_-.4---- N C7 ,----'0, - a ; ',.' ''' 1:'''. -------- .--- 4-• L: ..;'.'' ' 4 ' ' !" 444' 77 :: _ \k/...,----- .. • Se 14' '' ,, ‘4 i . ‘ .., _ ,....... ,...... co C . '., . 6.---- , 1'•-•4.1. --; t,-.I.1•.(.‘, ' t.4"---11*--- 1 ‘ r 'r t . 1-'•, ,.„•>‘ .., re,,":..,..• e .• tld , ' , ( 2) to e.r 'I:, ' I , ,„-,••-- ,„_.. ------ r. ').3 •--- • r ..1 i' 45-4 I 1',':.• ' ''' , , ;N7 1 .....,-- .........,.... ...,-',, „, ,.,...,. 111 ; j .•,,,, .........„-- , j -I. F.1 e 1 c) ......,.. ... , •"`..rj• ' !• "•". ,• . 1 •i. ,..„., . : ,:, (::;:.;_:_\ ,, ,..... ..... „......... .....„-- , . „... , c', II I t, ''..- . _ •. , , ... , lei , ; t c • I i Eie. t: Vg *I 1.1 $e op 1 i c A.AA d ,. . ,,,, -.1 1)- L I's'7( i'l, ,',".• c.:'A fi ra;Li ' \ M s. 1, ‘ '' •;",,,,,,;c•;•- - • ' \ , . . ....., -----vi ) 4. - lid 'le:. A/ k i f.,t r • i . ...3.64;4 • ' M ' t i ' ,------ )•,,,./ • ) , 0, —...... J.,-,,„;,,,, .,...._.......... _i 4..0'. .• Ld---- ?....),,/,‘. , , . 12 1"\ \. • T t.1..4:.,c i . .., ,. C, • , , \ 0'1 t ' s 0 . • a 0 ......, ' I VI i 0 „....4 LA i• — 4.rs, CD 0 1 .4.....-.E \ , , .„.... . , , -,.. E +. •=.1- 7.-E ! . M \ 1. CD \I t r• "V S \ t , - 3 r U) t 3 3 .. .. I i 1 '• .0 `r, V \ 'I T)• =73 \ L \ I I Z tri >3 ik ::._.1 rn -0 , '1k —1 r: \ trl C4 Olt 0 0 ,,, 6.•• 4 >d c-,-",%-..., , Q r'n , • --mir•-•-'-,.. \ 1 _.......... ,...., ar• i r,-0 .... .. Na tri mil aPPTIblVVO ...- .... 1:== ''''''' CD C) till .. gin... / 7- r--- • / Fri ;t• 0 V , ' ____...-----\''' ::. ,4, ;,,t ;-', il ...2._ .:•.• i •.;b: : , t -- I .......-------- \•`:, ." . . al i:.9 cob, JEFFER COUNTY ° CEIV I ` 3 DEPARTMENT OF COMMUNITY DEVELOPMENT A 621 Sheridan Street • Port Townsend • Washington 98368 4, ,, 360/379-4450 • 360/379-4451 Fax ,gS, NoO www.co.jefferson.wa.us/commdevelopment Master Permit Application WC 0 N CNC tdiS t a., 1 c e nip ratIMPTAMMANNIgaMrp - r ► c (,g.T► \CL'i le_rz 0 r Tt-- 1t c9 Z9, Tro ( L Q 2 ) _Aida r i Property Pini.=.#0• ‘ ,. , CI E;1 i ( .N - n s 9. Size: 5 �� � C�,�_rC. j (acres/square feet) (^t r t�t clC� siah /o.:Directions to Property: O)., , i�k e(�[�, (�/21 ue I Yl'1 GL C_11.YY1 � m 2t��i3 VNeA( Prpper Y3bviiner s)of Record: R OC"fEf 4 PArmti0-7-r� i-a o' �' si6h} " e --4 3coo-,:w5--o. ,. a e.Fax: � Co 3�` 3k f � �us.t � a. � email: r h��h2_�© (� I OA, l\oca t DRi u� atnhr)k ' it 4 - Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) Iir Building 0 Variance(Minor,Major or Reasonable Economic Use) 1 Demolition Permit 0 Conditional Use[C(a), C(d),or C]** ❑ Single Family 0 Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached 0 Special Use(Essential Public Facilities)** )-Manufactured Home 0 Boundary Line Adjustment 0 Modular 0 Short Plat** ❑ Commercial* 0 Binding Site Plan** ❑ Change of Use 0 Long Plat** ❑Address 0 Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments** 0 Propane 0 Plat Vacation/Alteration** ❑Allowed "Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** 0 Stormwater Management 0 Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance 0 Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment o Wireless Telecommunication* 0 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 ._,_., P a mt_e_CL. KLL 6 g__ _,,c_e,t__),_ 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 mponsibility fopadhering to and comp{yin g !ith the ESA,The Applicant has read this disclaimer and signs and dates it below. 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 assuming the responsibility of the General Contractor for the proposed project. I —c..(,, Slgnature lJ�lt/�( i '�' J�.� Il__ D��'iC-�-�/L.- Rat,:# "l 10 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL 'rtiiii P YP* �Sathrobms: 7IPe !I► , New Wood Existing: _______ ❑ Sewer ❑ Addition (Steel Proposed: fi? Bank Height: ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: _I___ h( ,'Individual System ❑ Repair 0 Masonry :,,, :, r ` SEP Permit# Demolition 0 Other: el3edrooms Vya upp y: Existing: 9s Setback: ❑ Private well 0 Two Party Type of Heat: , Proposed: 0 ( �. 14,Public e_i C-) - rr I C� Total: .I" I Name of System: 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: 0 Underground Tank 0 Above ground Tank Size of Propane Tank: 0 Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ 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, includin. the reserve area. Square Footage Current Proposed , riff,, ; ,j. <,, rt -:. . r. ^-'' •,., . mg __ 4, , e. , ' Main Floor Heated EH BId App Review: 2nd Floor Heated Consistency Review: l4 nyN 1kr Other Heated ) -,rs "I Base fee: r - Mezzanine ; Additional Section: ________.-. Heated Basement 'x: Plan Check fee: Unheated Basement �4 . _., State Surcharge fee: A ,--z) ,,,,,,,,t,..1 Other Unheated 7,3!-InXIM, Pot Water Review fee: __ Garage/Carport SUBTOTAL r=F --' uU Decks 911/Rd Approach fee: CV L i;t::6� Other ,, ,,i44 < TOTAL: $ )i y t 3xrwi: ; Receipt Number: S )( ri° ; Cash/Check Number: ,'I 5) ESTIMATED COST(REQUIRED) Date: S O6 •Fair market value of all labor and materials foundation to finish Initials: _1 G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc