HomeMy WebLinkAboutBLD2006-00477 itUILDING PERMIT •
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00477 Received Date: 8/18/2006
SITE ADDRESS: 341 SUNSET BLVD Issue Date 4/17/2007
PORT TOWNSEND, 98368 Expiration Date 4/17/2008
OWNER: MICHAEL B DEVENEAU PHONE: 360-385-3916
141 SUNSET BLVD
PORT TOWNSEND WA 983688913
CAPE GEORGE COLONY DIV 2
SUBDIVISION: Block: 4 Lot: 27
PARCEL NUMBER: 938100427 Section: 13 Township: 30 N Range: 02 W
CONTRACTOR: OWNER BUILDER PHONE:
PROJECT DESCRIPTION: NEW SFR WITH ATTACHED CARPORT
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,701
VALUATION 341,595.00 ADD'L: 378 HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: 1,303 HEAT TYPE:
OCCUPANCY: R-3
OCCUPANCY: UNHEATED: :390 #OF STORIES:
CONST TYPE: 5N OTHER: 711 SHORELINE:
GARACONST TYPE: DECKLE 531 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: CAPE GEO Type Amount Paid By: Date: Receipt:
BEDROOMS: BATHROOMS: Permit $2,348.95 CJZ 08/17/06 81437
Exist: Exist: Plan Check $1,526.82 CJZ 08/17/06 81437
Prop: 2 Prop: 4 State Building Code $4.50 CJZ 08/17/06 81437
Total: 2 Total: 4 Potable Water Application $55.00 CJZ 08/17/06 81437
Total: $3,935.27
Directions to Site:
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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
SPECIAL CONDITIONS APPLY - SEE ATTATCHED
• •
CONDITIONS for Building Permit# :BLD06-00477
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on August 25, 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:
SUSC aquifer recharge area; coastal SIPZ.
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.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
5.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
6.) 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.
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 COAST.,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.) 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.
10.) 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.
11.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
12.) The applicant is proposing to create or add 4963 square feet of impervious surface and
5524 square feet of land disturbing activities.
13.) 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.
14.) An Engineered Stormwater Plan dated April 6, 2007 prepared by Patrick Herbig, P.E. has
been submitted and approved by the Department of Community Development on April 17,
2007. 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.
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 revised site plan as dated April 16, 2007 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 April 17, 2006 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
17.) This approval is for a single family residence with attached carport 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 inoperab9hicles shall be stored on any lot unless tey
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 Sunset Boulevard right-of-way shall be 20 feet. Minimum side and
rear yard setbacks shall be 5 feet.
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.) The lots have been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
27.) An address of 341 Sunset Boulevard, Port Townsend has been assigned to the lots.
Sunset Boulevard is a private road (P165).
28.) The lots were created through the Cape George Colony Division 2 Subdivision on July 18,
1961 under AFN 168941.
29.) Potable water is supplied by Cape George Colony public water system.
30.) A septic permit (SEP99-0179) is now filed with SEP05-0282 that was approved on
November 7, 2005. A pre-app was withdrawn on December 6, 2001. A SPAAD
(ZONO2-0019) was finaled on August 18, 2006 for a single family residence. A wet
season evaluation (OTH99-0028)was submitted to EH. A critical area review
(CAR99-0475)was finaled on January 14, 2002. A critical area review (CAR00-0465)was
finaled on October 30, 2000.
31.) A Declaration of Restrictive Covenant was recorded on August 21, 2006 under AFN
514639 for the purpose of consoldating Lots 27 & 30 Block 4 of Cape George Colony
Division 2 to meet the minimum on-site sewage requirements and to allow encroachments
over the common lot line between the lots as the county does not have a zero lot line
setback.
32.) A geotech evaluation dated March 7, 2005 was prepared by Stratum Group for this lot.
The evaluation stated that the lot is not at risk of being impacted by slope failures. A letter
dated April 9, 2007 was submitted by Dan McShane of Stratum Group that addressed the
engineered stormwater design and the previous evaluation that he did for the lot. The
letter stated that the stormwater infiltration area and infiltration of water at the proposed
location between the home site and Sunset Boulevard will not cause any slope stability
problems on or off the site.
33.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT AN
ORIGINAL WET-STAMPED WRITTEN LETTER FROM PATRICK HERBIG, P.E. (LOW
IMPACT CIVIL ENGINEERING, PO BOX 65229, PORT LUDLOW WA 98365) STATING
THAT THE STORMWATER FACILITY HAS BEEN CONSTRUCTED IN ACCORDANCE
WITH THE REQUIREMENTS OF THE "DRAINAGE FACILITY" LETTER DATED
NOVEMBER 26, 2006 AS SIGNED BY PATRICK HERBIG, P.E.
fra
'BUILDING PERMIT APPLIC ATION ML ReviewTy 466
Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00477 Received Date: 8/18/2006
SITE ADDRESS: 341 SUNSET BLVD
PORT TOWNSEND, 98368
OWNER: MICHAEL B DEVENEAU PHONE: 360-385-3916
141 SUNSET BLVD
PORT TOWNSEND WA 983688913
CAPE GEORGE COLONY DIV 2
SUBDIVISION: Block: 4 Lot: 27
PARCEL NUMBER: 938100427 Section: 1:3 Township: 30 N Range: 02 W
CONTRACTOR: OWNER BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW SFR WITH ATTACHED CARPORT
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,701
VALUATION 341,595.00 ADD'L 378 HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: 1,303 HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: lOtilA- 390 #OF STORIES:
OCCUPANCY: OTHER: t
CONST TYPE: 5N GARAGE:Cftt2(DO 711 SHORELINE:
CONST TYPE: DECK: 531 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: CAPE GEO
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: X').-- Prop: 2 y
Total: 'L Total: g: ►}
Routing Date: I )l/O/
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $2,348.95 CJZ 08/17/06 81437 AFIDROJEE
Plan Check $1,526.82 CJZ 08/17/06 81437
State Building Code $4.50 CJZ 08/17/06 81437 APR (7 2007
Potable Water Application $55.00 CJZ 08/17/06 81437 Jefferson County Planning
Total: $3,935.27 & Building Department
Sent By: Bombardier Aerospace; 360 379 9471 ; Aug-14-06 2:56PM; Page 1 /2
• •
I LO,aQ-- '477
STRATUM GROUP
1451 Grant Phonce(360)Bellingham,
714 9 09 WA 98�25 AUG 1 8 73Oh i
!
March 7, 2005 1 !y
`r
Mary Deli eneau ( ` '
141 Sunset Blvd. _.
Port Townsend, WA 98368
Re: Engineering Geology Evaluation
Block 4, Lot 30 and 27, Sunset Blvd, Cape George
Port Townsend,Washington
Dear Ms DeVeneau:
I visited the above lots on February 16,2005 to qualitatively cv uate the slope stability and
drainage issues on the slope of the proposed home site. It is my+understanding that a septic site
has been permitted on the south lot and would be t►tilired by tinthome on the north lot.The
purpose of the site visit was to assess the slope and soil stabilit and drainage issues on the north
lot and provide recommendations for development of the site.
Based on my assessment of geologic conditions, the lot is not a risk of being impacted by slope
failures. Fill soils and organic soils beneath the lillpotentially ► uld cause settlement problems
for a home on the site.This can beavoided by fO_ ing_the ho e on good bearing oils beneath
the till and buried organic soils.It is my understanding that a d:ylight basement foundation is
being considered for this site.This type of foundation will be ' •ble at this site as long as all
till soil and organic rich soil buried beneath the fill is removed .rior to construction of the
foundation. A M71.D N l At c (
Because of shallow ground water within the soils at the site,att ntion to foundation drainage will
he particularly important. I suggest that the daylight basement foundation drainage system bea.
carefully designed to allow for complete drainage from behind he back wail and slab floor of the
daylight basement. This can be accomplished in a variety of w,i s including well sealed
foundation and slab walls and well draining gravel and drainag lines placed along the outside of V
the walls and beneath the slab foundation. As I suggested to yo at the time of my site visit, it is W my opinion that some over design of the drainage system woul be well worth the extra costs that
may be entailed to ensure that the foundation remains dry. The -xtra design could include ....1
additional drain rock and drain lines,and I suggest that clean o t risers be provided for the drain
U.
lines so that they can be readily maintained in case of clogging.
GEOLOGY
This geology description of the area is to provide some background regarding the conditions at
the site and why shallow ground water is present an the site.
Northwestern Washington has been occupied by continental gl ciers at least four times during
Sent By: Bombardier Aerospace; 360 379 9471 ; Aug-14-06 2:56PM; Page 2/2
?UU�
AUG 1 8 .
March 7,2005
4
Sunset Blvd Lot,Cape George, WA .--
Geology Assessment yT
the Pleistocene Epoch(1.6 million to 10,000 years ago). During1these glacial and accompanying
interglacial periods, the underlying bedrock was deeply erodedlh
e Surficial Geologic Map of
the Port Townsend 30-by 60-Minute Quadrangle, Puget Sounegion, Washington(Pcssl.
Dethicr, Boot and Minard, 1989)and the Geologic Map of Norastern Jefferson County
(Gayer, 1976)indicate that the subject property is located near contact between advance
outwash deposits and underlying glacial and nonglacial sedimery deposits. Site observations
on the subject property and in the vicinity are consistent with tabove-described mapping.
The slopes above the property appear to be underlain primarily sand and gravel outwash
deposits. Sand and gravel and silt in a very compact conditionpresent on the subject property.
No silt or clay layers were observed within the ditch on the subject property, but I have observed
very compact clays on along the shoreline below the subject property and on other properties in
the vicinity.
Advance outwash deposits were deposited by melt water stre s as the glacial ice advanced over
the area. The outwash exposed in the area is predominantly san and gravel. However, advance
outwash deposits tend to grade finer towards the base of the unit.
f
Layered silts and clays and some fine sand layers all in a very c mpact condition underlay the
advance outwash on the steep shoreline slope to the south of th subject property and silts and
clays in a very compact condition are present along the shoreli •below the subject property. The
silts and clays are consistent with the descriptions of the Kitsap Formation.
The presence of silts and clays within the either the lower part f the outwash deposits or the
upper portions of the preglacial deposits is the likely cause of s 11ow ground water being present
at the site. The well drained sand and gravel outwash deposits en the slopes above the subject
property allow for hydrostatic head such that the water can reac the proposed building site even
though a cut off trench has been excavated behind the propo: building site area.
We appreciate the opportunity to be of service to you. Should ou have any questions regarding
our reconnaissance please contact our office at(360) 714-9409.
Sincerely yours, n a
S turn Croup 44/ 4,0�.
3., ,.id
Dan McShane, l,.b;.G.,M.Sc. \+ }'ib -
Licensed Engineering Geologist f4 .-; _ -''044-
4 f A'-
Daniel M a=111 rik.1 14 OS
2
• •
R U
LOW IMPACT CIVIL ENGINEERING Pc. APO - 6 2007
PO BOX 65229, Port Ludlow, WA 98365
360-581-9497 JEFFERSON COUNTY
DEPT.OF COMMUNITY DEVELOPMENT
November 26, 2006
Mary& Michael Deveneau
141 Sunset Blvd.
Port Townsend, WA 98368 P
RE: Engineered Drainage Report for
Block 4, Lot 30 & 27
(341 Sunset Blvd. Port Townsend, WA 98368) JLtI LHSON C(IIi TMY ACC
Dear Mr. & Mrs. Deveneau:
On September 28, 2006 we met at your proposed building site (341 Sunset Blvd). I
observed very healthy wetland like vegetation throughout most of the site as well as
approximately 1.5 gallons per minute of groundwater exiting to the adjacent roadside
drainage ditch. I was informed that Jefferson County has requested an engineered
drainage report to be reviewed by Jefferson County, your geologist, and your onsite
septic designer.
DRAINAGE FOR HOUSE; Attached are details for a drainage system to keep the
proposed construction site free from ground and surface water. See the attached
subsurface drainage details. As was mentioned in the Stratum Group report, the entire
foundation& footing should be drained using a network of 4 inch perforated PVC pipe.
The 4-inch perforated pipe should have several clean-outs at the upstream portion of the
drain pipes. It is my recommendation to bed the pipe in 12-inches of 1.5-3 inch clean
crushed rock and then bridge this layer with 12-inches of 3-inch minus structural fill. See
attached calculations for drain pipe cover.
DRAINAGE MODEL; The Western Washington Hydrology Model 3 (WWHM3)
software program was used to determine the size of the trapezoidal stormwater
infiltration area necessary to treat the surface water and ground water from the site.
APPROVED
STORMWATER PLAN
is
Stormwat r
APR 1 7 2007
Require
JEFFERSO e,UNT
DEPT.OF 11 )EVELO E
SIGNATUR : - 1
• •
TRAPEZOIDAL STORMWATER INFILTRATION AREA; The dimensions of the
bottom of the area are 8-feet by 8-feet; the depth of the area should be 5-feet. With side
slopes of the area at 3 to 1 the dimensions at the top of the area will be 38-feet by 38-feet.
The outlet riser height should be 4-feet and the orifice diameter should be '/4 -inch (1/2—
inch is acceptable if -inch cannot be installed). Also, there should be a rock lined
overflow spillway at a height of 4-feet. All these dimensions should be reflected in the
site plan and/or details for the stormwater infiltration area. The area set-backs need to be
at least 10-feet and the area should be lined (if glacial-till is not present) with compacted
glacial-till. WWHM3 calculations are attached and I have attached a sample stormwater
infiltration area with details.
SITE PLAN; The site plan should show the 4-inch perforated pipe and the 4-inch house
downspout tight lines coming together in a small catch basin well below the grade of the
subsurface drains as to prevent any back-up into the perforated drain pipe. The drainage
should be conveyed from the catch basin via a 6-inch tight line, or a rock lined ditch, to
the trapezoidal stormwater infiltration area. The trench for the 6-inch tight line should
also act as a French drain to pick up drainage form the driveway; this should also be
indicated on the site plan. All other drainage on the site should be directed to the
trapezoidal stormwater infiltration area via ditch and/or pipe.
I hope this will provide the necessary information to complete your site plan and obtain
the necessary building permits. Should you have any question about this report or any
other matters please contact me directly at 360-581-9497.
Sincerely, ,cocK s.yFi4
q�4,oF w�sy�4,
Z 1 / O ,EA
� � ��
SIONALO
Patrick Herbig, P.E. I EXPIRES 2/27147 I
Low Impact Civil Engineering, Pc.
JEFFERSON COU� ITTITI"5'
l ,.
r I' DEPARTMENT OF CO UNITY DEVELOPMENT
` `Q 621 Sheridan Street• Port Townsend •Washington 8368
360/379-4450 • 360/379-4451 Fax
t�, AUG 1 8 2006 ,
.�rS, NG,,p wVVw.co.jefferson.wa.us/commdevelopment
-tirI
Master Permit Application i MLA: 0 t4t rTc- I
Project Description(include separate sheets as necessary)://�,
i�'e /4 77 4 C/Yi' �%Aze,re) T A2'6-----cis
•
Tax Parcer 3 a--/0 0 43 0 Property 77,
Number: g 3 c- _/o o 4 Z 7 Size: 2-de 6-re) (acres/square feet)
Site Address and/or Directions to Property: -AI/ ,, I�[�
/Property Owner(s)of Record: ///G/Q'/ �e've",.,,-a
Telephone: 3e00- 8 : 9/ Fax: r, email:
Mailing Address: /z// - cLnavit 13/vd / r7/ezu-iza,ut, Ltl-,
Applicant/Agent(if different from owner): G.D, ',4,,c,G<J v
Telephone: Sao — 88'Si—87/.s Fax: Z 3 — 2 - — y.s/ email:
Mailing Address: .7724 Al4c/T,c /l.✓y C-. , ii Fa ✓4- q f(4zy
What kind of Permit?(Check each box that applies)
pBuilding ❑Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cj**
1)Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
❑ Manufactured Home 0 Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑Change of Use ❑ Long Plat**
El Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
0 Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** ,
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate A)ud yQ"lup to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date: eg/7-06
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 attomey'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. j)h
Signature: teittl--- ' Date: cP/?.OI
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-t_ cable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: �i�� r �� Date: A/7 0(,
G:\PemvtCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT .
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that the rrOE Iiderise sTcontraahrs and that ,1they will be_si.SglIming the responsibility of the General Contractor for the proposed project. p {-. (^ 1
Signature: AeLti- ¢!i—e+t.A'c!-c.�1. Date: d' 17 D 6 } A AUG 1 8 2006 :_:;, i
? 1
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: L— FAX: -
NTY
( ) ':— ( .� ) „ , UEVELOPMENT j
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:
g New PS Wood Existing: ❑ Sewer
0 Addition ❑ Steel Proposed: 3 Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: .3 Height: Ig Individual System
❑ Repair ❑ Masonry SEP Permit# b5- Z S�—
0 Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ ,Private well 0 Two Party
Type of Heat: Proposed: 1-- Public
Gc�cT Total: Z.- Name of System:
/1050C
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current Proposed: 3 Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed 2_
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 El Above ground Tank Size of Propane Tank:
❑ Heat Stove 0 Cook Stove ❑ Woodstove ❑ Fireplace Insert 0 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,
including the reserve area. .
Square Footage For" Ce:Utg#t O.ily J..�iF ,; ` ,•'"
Current Proposed r ff 5?�!����, , ny J r'� }
Main Floor gypo �, Q'�} �dnststsnc r Rieyi W' P r "� § ' � -.
..:..rs'-•. 1:::,:',.'.f.::'.. .:,::-.,: ::::',J.;.::.::!i, .,:•„:.•,1,NVi-,‘*4.-.::., R.,,,.,,,::,..4,,.,,,,,,,„„ z„,„,,:_,,:;_,.,,„,
2""Floor 3 7 + t b k ` u ti y �"7+
-^�V 4 + ) Y x+y'-. .�PK e evi tad K,,x ?:
`•/y✓ (,r k x :r t5 Y}, ,,, ;,.Y,r} r t C'�: .,:,1„;. -fr
•3f3 Floor .` .' , 1tl+d�IQpel eCtlt-t :
Mezzanine: elan Gk•,.• -: Tom# ,, 3g. ry
Heated Basement r 1 ' ° y.fif } Fy y l
Unheated Basement 3 Q D rf lbh 0, x+: ; yY a x ,f
- 1 rr i3 :,t' i•
d �. ? <d�i � is su 4,
• t ' 'Other Unheated K R Ap acfe r M �!,.; 33 J <.s ,
Garage/Carport16
y
4i :Zl is s."i5t.°t-1'''''" ' : :5.:•'...':14;ttnr%1Ar 74 1`t L k? 1
Decks i w` fr t;y e r� l 1 ' bra YN; r tyke. n.:
�;/ lq,;t4 l'a t-N ltqii r� t v ,t�, 4, rf
AFC '�y'/�! ,,g,F ♦ t'MYl` �r�t �+' �'3 tt``".d tail.n�fif .��g �a S.
-Other, a 6 t"b 3NOM gi' n 7''''"a4F' I s ^k''�-if6 kr 'F 4 ` 1 k
T
ESTIMATED COST(REQUIRED) �j4p. t T } y° rI ®Y'^l t t 7 r t -+t.�i' ;,,,,,,,,,,,,,,,,,,,,..0,,,v,,,„,;,,,::_.,,,,� Y .". 1,4,,,,,•Fair market value of all labor and materials foundation to ,Wish ; "]] YY , �v' r�vi `?Ip/J +f`�^ r o r �aKt a � 1h�Ru. u't-]�y�. 7. S� �'
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