HomeMy WebLinkAboutBLD2006-00472 itILDING PERMIT APPLICATeN M Review eviewT0465
T ype: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00472 Received Date: 8/16/2006
SITE ADDRESS: 248 ROBINSON RD
BRINNON, 98320
OWNER: MICHEL D JEROME PHONE: 206-632-6349
JENNIFER I MYHRE
4135 ASHWORTH AVE N
SEATTLE WA 981038147 THACKER SHORT PLAT
SUBDIVISION: Block: Lot: 2+
PARCEL NUMBER: 502153052 Section: 15 Township: 25 N Range: 02 W
CONTRACTOR: TRUMAN CONSTRUCTION LLC PHONE: 360-871-2676
1905 VISTA LN
BREMERTON WA 98312
Contractor's License TRUMACL974N8 Expires 9/14/2007
REPRESENTATIVE: ROGER MYHRE PHONE: 206-632-6349
4135 ASHWORTH AVE N
SEATTLE WA 98103
PROJECT DESCRIPTION NSFR W/A/C-120 GerPR N-K 01(i
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 339,000.00 MAIN: 1,952
CODE EDITION: 2003 ADD'L: 1,398 HEAT TYPE: EEE
OCCUPANCY: R-3 HEAT BASE: t)`I`1C.) HEAT TYPE: HTP
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: 5N OTHER: ef0 SHORELINE:
CONST TYPE: GARAGE:
DECK: 264 SETBACK: 30
BANK HEIGHT: 9
SEWAGE DISPOSAL: ALT
WATER SYSTEM: 2WELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 4
Total: 3 Total: 4
Routing D te:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $2,332.15 LYK 08/16/06 84713
Plan Check $1,515.90 LYK 08/16/06 84713
State Building Code $4.50 LYK 08/16/06 84713 n
Potable Water Application $55.00 LYK 08/16/06 84713
Total: $3,907.55
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BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00472 Received Date 08/16/2006
SITE ADDRESS: 248 ROBINSON RD Issue Date 10/24/2006
BRINNON, 98320
APPLICANT: MICHEL D JEROME PHONE: 206-632-6349
JENNIFER I MYHRE
4135 ASHWORTH AVE N
SEATTLE WA 981038147
SUBDIVISION: THACKER SHORT PLAT Block: Lot: 2+
PARCEL NUMBER: 502153052 Section: 15 Township: 25 N Range: 02 W
CONTRACTOR: TRUMAN CONSTRUCTION LLC PHONE: 360-871-2676
1905 VISTA LN
BREMERTON WA 98312
Contractor's License: TRUMACL974N8 Expires: 9/14/2007
PROJECT DESCRIPTION: NSFR WING 120 GAL PROP TANK ` gat pitp S-F
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
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SETBACKS: /
UFFER: 1/
Footing: Ate 2 -1,-13l rYIPAk
Foundation: (0 ST aw" �'1-c_ "J -v / ,'^'V'
Stormwater FINAL Approval: 1
Underground Plumbing:
Underground Insulation:
Shear Wall : �, c 1%-i D�v� �'-2'2'- (4 A kj
Sheathing:
Framing: //2.1//$
Plumbing: 47k / /De-
Propane Tank/ Lines: 6 ii dK 04 o2
Insulation: AiR . E 4L ,� i/i,�fog W�us 'b Z. e
Sheetrock� --,?_)1 y
Septic Sytery Final Approval MUST be obtained before final of structure can be attempted.
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval: ‘, ( 2 0 . QL-x Co " je
ifoyu
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 rn. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY - SEE REVERSE
• •
SPECIAL CONDITIONS FOR CASE A BLD06-00472
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 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
single family residence and detached garage.
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 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.) 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.
10.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
• .
11.) 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.
12.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater,
erosion and sediment during construction. BMPs shall address permanent measures to
stabilize soil exposed during construction, and in the design and operation of stormwater
and drainage control systems.
13.) A stormwater plan for a medium project has been submitted and approved by the
Department of Community Development. Once the subject permit has been issued the
applicant shall fully implement the provisions of the submitted plan and contact the
Jefferson County Department of Community Development to arrange a schedule to
inspect the property for plan compliance. A Certificate of Occupancy will not be issued
until the Department verifies plan compliance. No clearing for roadways or utilities shall
occur on the project site until clearing necessary for the installation of temporary
sedimentation and erosion control measures have been completed.
14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
15.) 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.
16.) Minimum setback from Robinson Rd right-of-way shall be 20 ft. Minimum setback from
the existing bulkhead shall be 30 ft. Minimum side yard setback shall be 5 ft. However
the proposed single family residence and detached garage shall be setback entirely off of
the well and waterline easement along the eastern property line.
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.) Residential developers and individual builders shall be required to preserve shoreline
vegetation and reduce the associated risk of erosion during construction and any future
activity which may impact the stability of the shoreline.
20.) The building height is not to exceed 35 feet.
21.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
22.) The standard setback for residential structures, including common appurtenant structures
such as garages and workshops, shall be thirty(30) feet or one (1) foot for each foot of
bank height, whichever is greater. This setback shall be measured from the bank's edge
when the bank's height exceeds 10 feet. When the bank's height is less than 10 feet, the
setback shall be measured from the ordinary high water mark. The setback shall not
exceed 100 feet.
23.) All stormwater shall be infiltrated entirely onsite. All stormwater discharge shall be routed
away from the landslide buffer area. In addition, the water shall not be discharged over
the bluff. If stormwater is unable to be infiltrated onsite, a separate shoreline permit is
required prior to tightlining stormwater to the beach.
•
24.) A minimum of two (2) on-site parking spaces are required for the single family residence.
25.) Vegetation on the slope face provides stabilization to the slope face soils and should be
left in as natural state as possible. Large trees that are in danger of falling due to disease,
undermining of the roots, etc should be evaluated for possible removal and obtain
approval from Department of Community Development. Large trees that fall over on a
slope can cause considerable damage. If trees are removed as approved by Department
of Community Development, the trunk should be left in place so that the roots can
continue to provide stabilization to the soil.
26.) It will be necessary to maintain ground cover on the slope in order to reduce erosion from
surface runoff. Any bare areas that develop should be re-vegetated. Native small,
deep-rooted vegetation that requires little or no irrigation would be the most beneficial.
27.) Excavation into the toe of the slope should be avoided.
28.) Drainage control devices should be maintained in good working order and inspected at
least once a year.
29.) A"Construction Drawing" Flood Elevation Certificate was prepared by a licensed surveyor
and submitted with the application. The Certificate identified the base flood elevation of
10 feet. The lowest floor of the structure is required to be elevated at least one (1) foot
above base flood elevation or 11 feet. PRIOR TO FINAL BUILDING INSPECTION,
PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN ORIGINAL"FINISHED"
CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT HAS BEEN VERIFIED BY
A LAND SURVEYOR, ENGINEER, OR ARCHITECT AUTHORIZED BY LAW TO
CERTIFY ELEVATION INFORMATION IN THE STATE OF WASHINGTON.
30.) Flood proofing measures are to be used as required by the Jefferson County Flood
Damage Prevention Ordinance.
31.) All new construction shall use construction methods which minimize flood damage.
32.) New construction shall have the lowest floor elevated to at least one foot above base flood
elevation.
33.) Fully enclosed areas below the lowest floor that are subject to flooding are prohibited
unless designed to automatically equalize hydrostatic flood forces on exterior walls by
allowing for the entry and exit of floodwater. Designs for meeting this requirement must
either be certified by a registered professional engineer or architect or must meet or
exceed the following criteria: a. A minimum of two openings having a total net area of not
less than one square inch for every square foot of enclosed area subject to flooding shall
be provided. b. The bottom of all openings shall be no higher than one foot above grade.
c. Openings may be equipt with screens, louvers, or other coverings or devices provided
that they permit the automatic entry and exit of floodwater.
34.) All new construction shall: a. be anchored to prevent flotation, collapse, or lateral
movement of the sturcture. b. be constructed with materials and utility equipment resistant
to flood damage and potential damage to adjacent properties. c. be constructed using
methods and practices that minimize flood damage. d. have structural components
capable of resisting hydrostatic and hydrodynamic loads and the effects of buoyancy. e.
electrical, heating, ventilation, plumbing, air-conditioning equipment, and other service
facilities shall be designed and/or otherwise elevated or located so as to prevent water
from entering or accumulating within the components during conditions of flooding.
35.) Flood proofing of structures shall be provided by one or more of the following methods: a.
Landfill: (Note: Landfills are not permitted in the floodway.) The placement of fill may be
utilized to elevate the structure and must comply with the standards and policies of the
Jefferson County Shoreline Master Program, if applicable. b. Pole, pier or piling
construction: The use of poles, piers, or piles for the foundation of the structure may be
used to allow the unrestricted flow of flood waters during periods at a base flood. The
lowest floor must be one foot above the base flood level. c. Parallel Foundation Walls:
Foundation walls may be designed and constructed to provide open spaces through which
water can flow unrestricted to equalize pressure. In velocity flood situations, it is important
that all foundation walls be parallel to the flow of the floodwaters. d. Extended Foundation
Walls and Basements: (Note: Extended foundation walls and basements are not permitted
in the floodway.) The lowest habitable floor of a residence may be constructed on
foundation walls that extend above grade to one foot above the height of the base flood
provided that residential construction complies with the requirment of Section 5.101(2),
"Residential Construction," regarding the design of enclosed areas.
36.) Utilities shall be designed as specified in Section 5.20 of Ordinance No. 18-1120-95.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
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DEPARTMENT OF COMMUNITY DEVELOPMENT A.
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http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
IMLA# �� f, - t I(.�1`> PROJECT/APPLICANT NAME: (Y`` INEL
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 map.
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2. Describe the existing topography. Indicate contours on the site map. O> 6 O 4 7 2
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3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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5. Describe the existing site hydrology(i.e., drainage;behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of each.
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APPROVED
6. Describe any excess levels of noise generated by the proposed use or activity: STORM WATER PLAN
N/A
OCT - 5 2006
JEFFERSON COUNTY
DEPT.OF C1Q�lM�UNI VJ� t
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stormwater see plan template—rev.10/1/2003 ✓,
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes, etc.)on the site. Indicate location on the site map.
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8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads,and sensitive/critical areas
(streams,wetlands,lakes,steep slopes,etc.).
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
9.
Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual) or, if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed
for use on the site.. Locate these facilities on the site plan'and differentiate proposed facilitied 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.
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2. Destctibe the flow control system.
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stormwater site plan template-rev.10/1/2003
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13. Describe the water quality system.
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material, and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
N/A
17. Describe the proposed surfacing material.
18. Describe methods for restoration of the site.
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
"large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here.
1V/A
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
N(14
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.
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stormwater site plan template—rev.10/1/2003
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• •
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I—CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits.
2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls. • .
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5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets.
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stormwater site plan template—rev.10/12003
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12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs),
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12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads).
N/A-
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). cetn:...-
N/A
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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stormwater site plan template—rev.10/1/2003
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• •
b. Description of special requirements for working in or near environmentally sensitive areas.
N�R
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility, settleability,permeability,depth,texture,soil structure).
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5. Construction Phasing.
a. Construction sequence
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ID. Construction phasing(if proposed)
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule. •
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Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps. N
b. Diversions. N I A
c. Waterways. N( R.
d. Runoff/Stormwater Detention Calculations N
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stormwater site plan template-rev.10/1/2003
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Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan,the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems, treatment facilities, flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property.
F ,Z v o (o
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(LANDOWNER 0 UTHORIZED RE SENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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stormwater site plan template—rev.10/1/2003
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C4i 061 JEFFER, 1 COUNTY 9 + r �
1 DEPARTMENT OF COMMUNITY DEVELOPMENT �� � ��1�J1
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`� 621 Sheridan Street • Port Townsend • Washington 98368 _
360/379-4450 • 360/379-4451 Fax
�rYS.�N��O� www.co.jefferson.wa.us/commdevelopment
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Master•Permit Application _
Project Description(include se 'MLA'
'separate sheen as necessary):` r, ,t. ,
- cC OR E • • 4. L• •
L' - 'y 't1 Ok%'-' 4 6-., "A''• tac. GPtL. P cYt'i `T�
Tak Parcel Number: :` sj•pa,�53p� Property NK
• Size:'l.85$a.}. :80:ctS1 •c:( (acres/square feet)
.' 5ite Address and/or biiectionsto`Pro ert `� � ••
Property Owner(s)of Record:M\C' L « m� ;
N� �ENN� --R M��ce
Telephone: ac,G- Q �
3a-Cil 4 Fax:
Mailing Address: t-___ ct ACNs.�Q-t AVf email:. : ccerv�p.,.,.,,t^t •� CS•CoM
•Applit;antiAgent(if different from owner):_ �C2 rn,
Telephone: I -f�to • . yq
Fax:
Mailing Address: y - email: MkS
What kind of Permit?(Check each box that applies)
RF�to� V° •e4m
t6Building
•
❑ Demolition Permit ❑ Variance(Minor,Major or Reasonable Economic Use)y,
.Single Family ❑ Conditional Use[C(a),C(d),or C]**
❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached
El Manufactured Home ❑ Special Use(Essential Public Facilities)**
❑ Modular GIBoundary Line Adjustment
❑ Commercial* ❑ Short Plat
❑ Change of Use ❑ Binding Site Plan**
q Address ❑ Road Approach ❑ Long Plat*"
ID.'Propane Planned Rural Residential Development(PRRD)/Amendments**
Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑
❑ Allowed
Stormwater Management ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Substantial Development**
❑ Temporary Use ❑ Shoreline Management Variance
❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication*
❑ Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*Ma r••uire a Pre—A••iication Conference **R
Please identify any other local, state or federal permits required for this proposal, if known:erence
I hereby designate DESIGNATION OF AGENT •
s..- - t i act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Aa 41j:t.(�/ '
t1 `G Date:
By signing this application form,the o ner/agent attests t at the in ormation pro L. d 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: Mir
----_ Date: a - 2, — o o C.
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 tefms are defined in the federal law ttho4vn-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
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 resp " ility for ad eying to a complying with the ESA. The Applicant has read this disclaimer and signs and dates it below your action(s)
Signature:
--- Date: $- a — 2,t) a 6
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.
Signature: Date:
FAX:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE:(�p0) $�,^a��� FAX: "`�3`I 5
`A'RvcNtt.N cotJscc�vco c� N �--t-.0
EMAIL:•�-ruM�,nCQt‘St'Cv�"C‘0r1 vyo..hCa.Co M
MAILING ADDRESS: ����• V\ A PVtc �REM�CtTON s
c1g3t . WAINS �.r.' '
CONTRACTOR�SL�CNSE. r p a . NUMBER G(�`C.tNSS�tS`at
•
NUMBER:' ' -v M etc. L grttit4d ARCHITECT/ENGINEE /
-3
Rt PHONE 1• � ) '3(0'--t1�`l FAX: (3(40 )F4 ...8 3
'C�F�•••C.t'SL'�'N�co��..ECt�NCo \NC. EMaIL
MAILING ADDRESS: GCiSQ e-, „1e, �\\ COM�CA.S'C•n
14Qt*a"C�o R� CEt�RquR �W� �g��3� ,. �.� Type of Sewage Disposal:
Frarn`d TVp6: :/ •Bathrodms• Shoreline: 9 P
Project Type: � � ,• .:�:�; •.'� ❑ Sewer
New • Wood.!: • .... .'.'t. • Existing:r t >.:.r.'
j - ❑ Steel Proposed: - Bank Height: D Community System
Ti Addition io e ;• Total: WIndividual System
Alteration%Remodel ❑ Concrete ;q.E SEP Permit#PA'ft1E.) .6 �'of
❑ Repair L] 'Masonry" .Bedtddthi:" •1. •' ' _' .' Water Supply:
❑ Demolition ❑ Other: Existing: setback:• -• .,'.p' Private well X Two Party
I.'.Type o t e 7 roposed 3 • _ ..' .� Public:':
of Heat:. - ;;f.r ?, .P • Total: " "' Name of System:
•
ELE.CCKAC
If this is a Commercial Project you must answer the following: Number of ADA Parking Spaces:
Number of Parking Spaces: Current: Proposed:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
Type Occupancy:
IBC T e 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: —A Underground Tank 'Abolie ground Tank Size of Propane Tank: vacs 6 P.L i Li c:7.0 .
❑ Heat Stove ❑ Cook Stove [I Woodstove ii Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove VI Other coot",TDP
Is this appliance being installed in a Manufactured I Mobile Home? Yes /
aall
When applying for a permit to install a propane tank you must also submi • 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 l Current Proposed For Office Use Only
Amount Revision -:
Main Floor Heated t 7 4Jj 1.1 EH BId App Review: �J
\eksa
2n.Floor Heated I a-j >2,"1 4 Consistency Review: / C '
\`3��
Other Heated Base fee: . .,.,•;, ,
.a.,),..,,,
Mezzanine
Additional Section: —
C �
Heated Basement Plan Check fee: 15, 15.
Unheated Basement
State Surcharge fee: / , J, ' '
Other Unheated
Pot Water Review fee: GO oz)
Garage/Carport SUBTOTAL `� ��
'l .
Decks 4 p iq.72. 9• Fld Approach f e:` _—
Ici(o � �biIE ICCC1
Other 1(4,0-6 .US TOTAL: $ /.1 1(c0
Receipt Number: 1_,173 1 3
Cash/Check Number:
LI
ESTIMATED COST(REQUIRED) 3Z 8c1 e:Dat `-^��
,Fair market va 11 for add materials foundation to finish ICn)
Initials:
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