HomeMy WebLinkAboutBLD2006-00609 CERTIFICATE OF OCCUPANCY
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451 (800) 831-2678
PERMIT #: BLD06-00609
SITE ADDRESS: 580 MT CONSTANCE WAY Issue Date: 05/16/2007
PORT LUDLOW, 98365 Final Date: 1/11/2008
APPLICANT: PORT LUDLOW ASSOCIATES LLC PHONE:
70 BREAKER LN
PORT LUDLOW WA 983659766
SUBDIVISION: OLYMPIC TERRACE DIV 2 PH 1 Block: Lot: 11+
PARCEL NUMBER: 978802011 Section: 21 Township: 28 N Range: 01 E
PROJECT DESCRIPTION: NEW SINGLE FAMILY & ATTACHED GARAGE - 120 GAL A/G PROPANE
TANK
LOT 11
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2003 EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes no
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 1/11/2008
I:\F_BLD_Occupa ncy.rpt 10/29/19c
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BUILDING PERMIT I
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00609 Received Date: 10/23/2006
SITE ADDRESS: 580 MT CONSTANCE WAY Issue Date 5/16/2007
Expiration Date 5/16/2008
OWNER: PORT LUDLOW ASSOCIATES LLC PHONE:
70 BREAKER LN
PORT LUDLOW WA 983659766
OLYMPIC TERRACE DIV 2 PH 1
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 978802011 Section: 21 Township: 28 N Range: 01 E
CONTRACTOR: PORT LUDLOW ASSOCIATES, LLC PHONE: 360-437-2522
70 BREAKER LN
PORT LUDLOW WA 98365
PROJECT DESCRIPTION: NEW SINGLE FAMILY & ATTACHED GARAGE - 120 GAL A/G PROPANE
TANK
LOT 11
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2, 702
VALUATION 262,615.00 ADD'L: HEAT TYPE EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: HTP
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: '540 SHORELINE:
CONST TYPE: DECK: 327 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: SEW
WATER SYSTEM: LUDLOW Type Amount Paid By: Date: Receipt:
BEDROOMS: BATHROOMS: Permit $1,811.35 CJZ 10/23/06 85254
Exist: 0 Exist: 0 State Building Code $4.50 CJZ 10/23/06 85254
Prop: 3 Prop: 2 Potable Water Application $55.00 CJZ 10/23/06 85254
Total: 3 Total: 2 Permit $95.20 LYK 02/21/07 89432
Plan Check $1,108.66 LYK 02/21/07 89432
Plan Check $130.60 LYK 05/15/07 91055
Total: $3,205.31
Directions to Site:
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
Jefferson County Building Dieon Permit Num. BLD06-00609
Applicant: PORT LUDLOW ASSOCIATES LU
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2003 International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
Setbacks y
ye/7Erosion Control D �I
Foundation Footing 4//3/01 /
uPFEa Nsrpc1.4-0
Footingu/A
Foundation Stem Wall G/�D? j /
Underground Plumbing �-, �/ , 0/,A
Straps 9/0-/In 6�
Shear Wall Nailing 8/2i/67 ��. ALl ittu6 0se._
Rough-in Plumbing V/9/4 7 OZ�
Framing 9/8/v7 / uNn&ercmc DIC Aii/o7 D
Blocking 76707 ,
Airseal �o? oK
Insulation:Walls 04/07
/
Insulation: Floors ///1/08 '
Insulation:Ceiling ///D/0S
Int. Shear Wall Nailing
9//8/07 �• oSB oK fliB/r1G44
Wallboard Nailing /4/24 7
Gas Line: Interior IA017 gf Oi -Gas Line: Exterior 1.1
Propane Tank / D
Heat/Chimney Clearance V/8/07
Drywell/Alt Drainage �J
Address Posted /0
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD06-00609
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on February 9, 2007 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:
wetland.
2.) A setback of 50-feet, measured perpendicularly from the wetland edge, shall be
permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the
wetland or its buffer is allowed.
3.) Wetland buffer perimeters shall be marked with temporary signs at an interval of one per
parcel or every one hundred (100) feet, whichever is less. Signs shall contain the
following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation."
4.) A permanent physical separation along the upland boundary of the wetland buffer area
shall be installed and permanently maintained. Such separation can include installing
logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC
Administrator.
5.) The applicant is proposing to create or add 4330 square feet of impervious surface and
4616 square feet of land disturbing activities.
6.) 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.
7.) A Small Parcel Erosion and Sediment Control Plan has been submitted and approved by
the Department of Community Development. Once the subject permit has been issued
the applicant shall fully implement the provisions of the submitted plan and contact the
Jefferson County Department of Community Development to arrange a schedule to
inspect the property for plan compliance. A Certificate of Occupancy will not be issued
until the Department verifies plan compliance. No clearing for roadways or utilities shall
occur on the project site until clearing necessary for the installation of temporary
sedimentation and erosion control measures have been completed.
8.) 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).
9.) The revised site plan dated February 21, 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 May 15, 2007 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
10.) This approval is for a single family residence with attached garage and 120 gallon
above-ground propane tank 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.
11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
12.) 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.
13.) Minimum setback from Mt. Constance Way right-of-way shall be 20 feet. Minimum side
yard setbacks shall be 5 feet. Minimum rear setback for structures shall be east of the
"Native Growth Protection Easement (NGPE) as depicted on the face of the final plat.
14.) 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.
15.) Lighting fixtures shall be designed! hooded to prevent the light source fromOg
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.
16.) Maximum lot coverage is not to exceed 45%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
17.) The building height is not to exceed 35 feet.
18.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
19.) Per MPR Code Section 3.107, Accessory Dwelling Units (ADU's) shall not be allowed in
the MPR-SF zone.
20.) The lot has been designated as MPR SF-4:1 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
21.) An address of 580 Mt. Constance Way, Port Ludlow has been assigned to the lot. Mt.
Constance Way is a county local access road (C517009).
22.) The lot was created through the Olympica Terrace II Phase 1Subdivsion on May 10, 2007
under AFN 523326.
23.) A road approach permit (RAP06-0218) will be issued with the building permit.
24.) The lot is served by Port Ludlow water and sewer.
25.) THE CUTTING OR DAMAGING OF ANY TREE OR OTHER VEGETATION LOCATED
WITHIN A NATIVE GROWTH PROTECTION EASEMENT AREA DESIGNATED ON THE
PLAT IS PROHIBITED EXCEPT FOR THE REMOVAL OF DEAD, DISEASED, OR
DYING VEGETATION THAT PRESENTS A HAZARD; THE IMPLEMENTATION OF AN
ENHANCEMENT PLAN REQUIRED OR APPROVED BY JEFFERSON COUNTY; THE
LIMBING, PRUNING, OR SELECTIVE THINNING OF TREES AND OTHER
VEGETATION TO CREATE, ENHANCE, OR PRESERVE SCENIC VIEWS TO THE
EXTENT PERMITTED BY JEFFERSON COUNTY WITHIN NATIVE GROWTH
PROTECTION EASEMENT AREAS; OR AS MAY OTHERWISE BE PERMITTED BY
JEFFERSON COUNTY. ANY WORK, INCLUDING REMOVAL OF DEAD, DISEASED,
OR DYING VEGETATION, IS SUBJECT TO COMPLIANCE WITH PERMIT AND OTHER
REQUIREMENTS OF JEFFERSON COUNTY. JEFFERSON COUNTY SHALL HAVE
THE RIGHT BUT NOT THE OBLIGATION TO ENFORCE THE REQUIREMENTS,
TERMS, AND CONDITIONS OF THIS RESTRICTION BY ANY METHOD AVAILABLE
UNDER THE LAW.
26.) IN ORDER TO AVOID SIGNIFICANT ADVERSE IMPACTS TO SOILS AND WATER,
NATURAL VEGETATION SHALL BE MAINTAINED IN OPEN SPACE AREAS,
PROVIDED THAT REMOVAL OF DEAD, DISEASED, OR DANGEROUS TREES AND
THE SELECTIVE THINNING OF VEGETATION AND LIMBING OF TREES FOR VIEWS
SHALL BE PERMITTED PROVIDED THE HEALTH OF LIMBED TREES IS NOT
JEOPARDIZED AND SUCH ACTIVITIES ARE IN ACCORDANCE WITH THE
RECOMMENDATIONS PROVIDED BYA QUALIFIED FORESTER OR SIMILAR
PROFESSIONAL. PLACEMENT OF RECREATIONAL AMENITIES (SUCH AS A PICKLE
BALL COURT) SHALL BE PERMITTED IN ACCORDANCE WITH THE
RECOMMENDATIONS OF A LICENSED ENGINEER IN A GEOTECHNICAL REPORT.
27.) WOOD DEBRIS AND SLASH SHALL BE STOCKPILED AND BURNED AT A REMOTE
SITE LOCATED AT LEAST A MILE FROM EXISTING RESIDENTIAL DEVELOPMENTS.
EACH BURN SHALL BE REVIEWED AND COORDINATED WITN THE OLYMPIC AIR
POLLUTION CONTROL AUTHORITY, PRIOR TO BURNING WOOD DEBRIS AND/OR
SLASH, THE APPLICANT OR OPERATOR SHALL CONTACT THE OLYMPIC AIR
POLLUTION CONTROL AUTHORITY AT 1-800-422-5623 FOR ANY RQURIED
REGISTRATION OR PERMITTING.
28.) WETLAND BUFFERS SHALL REIN NATURALLY VEGETATED EXCEPT *RE
VEGETATION HAS BEEN DISTURBED, INVADED BY HIGHLY UNDESIRABLE
SPECIES (E.G. NOXIOUS WEEDS), OR WOULD SUBSTANTIALLY BENEFIT FROM
THE INCREASED DIVERSITY OF INTRODUCED SPECIES, WHERE BUFFER
DISTURBANCE HAS OCCURRED DURING CONSTRUCTION, REPLANTING WITH
NATIVE VEGETATION SHALL BE REQUIRED. MINOR PRUNING OF VEGETATION
TO ENHANCE VIEWS AND REMOVAL OF UNDESIRABLE SPECIES (E.G., ALDERS)
MAY BE PERMITTED BY JEFFERSON COUNTY ON A CASE-BY-CASE BASIS.
IIILDING PERMIT APPLICATION ML
Revviewiew T Ty 590
ype: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00609 Received Date: 10/23/2006
SITE ADDRESS: MT CONSTANCE WAY
PORT LUDLOW, 98365
OWNER: PORT LUDLOW ASSOCIATES LLC PHONE:
70 BREAKER LN
PORT LUDLOW WA 983659766
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 821213001 Section: 21 Township: 28 N Range: 01 E
CONTRACTOR: PORT LUDLOW ASSOCIATES, LLC PHONE: 360-437-2522
70 BREAKER LN
PORT LUDLOW WA 98365
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW SINGLE FAMILY & ATTACHED GARAGE - 120 GAL A/G
PROPANE TANK
LOT 11
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2,702
VALUATION 262,615.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE: HTP
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 540 SHORELINE:
CONST TYPE: DECK: 327 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: SEW
WATER SYSTEM: LUDLOW
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 2
Total: 3 Total: 2
Routing Date:
c)al1Crl
Type Amount Paid By: Date: F2eceigt: EAPPROVED
Permit $1,811.35 CJZ 10/23/06 85254
State Building Code $4.50 CJZ 10/23/06 85254
Potable Water Application $55.00 CJZ 10/23/06 85254 MAY 2007
Permit $0.00 LYK 02/21/07 Jefferson County Planning
Plan Check $0.00 LYK 02/21/07 &Building Department
Plan Check $0.00 LYK 02/21/07
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OCT 2 3 2006
! uEVELOPMENT
JEFFERSON COUNTY L��_ _:_
STORMWATER MANAGEMENT
SMALL PARCEL EROSION AND SEDIMENT CONTROL PLAN
EROSION AND SEDIMENT CONTROL WORKSHEET
Property Owner: Port Ludlow Associates Telephone: 437-2101
Address: 70 Breaker Lane, Port Ludlow, WA 98365
Assessor's Parcel Number:
Building Permit or Septic Permit Application Number(if applicable):
Brief Project Description: New Single Family Residence W/ attached garage.
Site Location:
Person Responsible for BMP Installation and Maintenance:
l
Address: same as ahnve
Telephone:Same as above
1. Describe/check the Best Management Practices (BMPs) that you will implement during land
disturbing activities or construction to control erosion and prevent sediment from entering water
bodies (marine waters, streams, rivers, lakes, or wetlands) or impacting adjacent property or
roads. Please check the measures you plan to implement and show their approximate location on
the site plan.You may also propose measures other than those listed. Attach additional sheets,if
more space is required.
[] Stabilize construction access route. Limit construction vehicles to one route, if feasible.
Provide a stabilized construction access by applying quarry spalls,ballast, or crushed rock
to minimize tracking sediment onto roads. (See attached illustration from Stormwater
Management Manual.) If sediment is transported onto roads, they will be cleaned
thoroughly.
[] Minimize the extent of land disturbing activity and preserve existing vegetation.
Preserve buffers of well-established vegetation between disturbed areas and property
boundaries, roads, water bodies, and designated critical areas (wetlands, fish and wildlife
habitat areas,landslide or erosion hazard area,etc.).
APPROVED
STORMWATER PLAN
SPESC Instructions—Short Form. ON C
Revised July 17,2002 ATe MAY 1 5 2007
DECf.OF
lEFFERSE OU y
Op
SIGNATURE:
OCT 2 3 2006
fl
}
EROSION AND SEDIMENT CONTROL WORKSHEET _;tV LJ' MENT
[] Phase clearing so that only areas that are actively being worked are uncovered.
[] Start and complete land disturbing activities and stabilize the site between April 1
and September 30. Stabilization means that disturbed areas will have well-established
plant cover or be landscaped to minimize erosion.
[> Stabilize exposed soil Exposed and unworked soil will be covered within 2 days between
October 1 and March 31 and within 7 days between April 1 and September 30.
[ ] Cover exposed soil with a minimum of 2 inches of straw or hay or other material
approved for this purpose.
[ ] Cover soil stockpiles with plastic sheeting and locate away from water bodies, roads,
and property lines.
[] Place gravel base on roads,driveways,and parking areas after clearing and subgrade
preparation.
[4 Protect adjacent properties and water bodies from sediment deposition:
[] Place straw or hay bales in ditches and drainage ways down slope from areas.
of land disturbing activity to filter runoff before it leaves the project site or enters
water bodies.(See attached illustrations from Stormwater Management Manual.)
[] Install a filter fence down slope from areas of land disturbing activity to filter runoff
j before it Ieaves the project site or enters water bodies. (See attached illustration from
i. Stormwater Management Manual.)
[X Regularly inspect and maintain all BMPs especially after storms events.
[] Describe other erosion and sediment control Best Management Practices. Be specific
as to design and specifications.
Site is very flat with sandy soils . So I believe the above
measures will be sufficient.
SPESC Instructions—Short Form
Revised July 17,2002
4
• •
EROSION AND SEDIMENT CONTROL WORKSHEET
2. Describe how disturbed areas will be permanently stabilized(seeded, landscaped,apply gravel base
to roadways,etc.)
Areas that are distrubed will be landscaped with natural
type vegetation and lawn to property line
3. Describe how runoff from impervious surfaces will be controlled (disperse to vegetated areas to
infiltrate,dry well,infiltration trench,route runoff to existing drainage facilities,etc.).
(
All impervinus sirrfares will he run to roof drains and
catch basins as designed into the plat requirements.
E ,
O
{
SPESC Instructions—Short Form
Revised July 17,2002 C. T 2 3 2006
?Y
5 1 oEVELOPMENT
I •
J
EROSION AND SEDIMENT CONTROL WORKSHEET
4. Specify your construction sequence. Describe the timing of all land disturbing activities (clearing
and grading, construction, installation of drainage facilities, landscaping, etc.) and Best
Management Practices. Describe proposed maintenance of BMPs.
After excavation the soil piles will be covered and silt
fence will be installed. Silt fence will be left in
place until we are ready to landscape and all roof drains/
• latch basins are in. Landscaping will be installed as
early as possible on the exterior of the building when
all exterior concrete work is completed.
( The Best Management Practices proposed above will be implemented to control erosion, sediment, and
stormwater runoff I will notify the Jefferson County for inspections as required.
14S . l a ( 19 106
Signature of Owner/•gent Date
17) W 7-7)'
OCT 2 3 2006
SPESC Instructions--Short Form
Revised July 17,2002 I
i • 6 Y
,ti-VEI.OPMENT JI
ON
, % JEFFERSON COUNTY
r �'c w : DEPARTMENT OF COMMUNITY DEVELOPMENT OCT 2 230
621 Sheridan Street • Port Townsend•Washington 98368
360/379-4450. 360/379-4451 Fax i
Ia1lOI5rnP acc www.cojefferson.wa.us/commdevelopment
Master Permit Application MLA: 0(0 —5°
Project Description(include separate sheets as necessary):
New $Ir'cfe eunt14 cesidrenoL u'iatick hed fa3e
Tax Parc Property —
Numbt_._ �7�1, Z-( � Size: )3r7&D (a s/squarefeet
Site Address and/or Directions to Property: til,T- Cc .C. 0 (....0lArt,,,
Property Owner(s)o Record: •• ao._ ;•, A. silf
Telephone: *0 LI 7• I Fax: 4 LQ�a - - a email:
Mailing Address: P A k A, . _—_I - 411111Wrin
•LA-) it •; (Q
Applicant/Agent(if different from owner): ft)l14
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Building ❑ Variance(Minor,Major or Reasonable Economic Use)
0 Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
X Single Family ❑ Discretionary"D"or Unnamed Use Classification
Garage i /Detached ❑ Special Use(Essential Public Facilities)**
0 Manufactured Home 0 Boundary Line Adjustment
0 Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
L Change of Use ❑ Long Plat**
X Address it Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
/4-Propane ❑ Plat Vacation/Alteration**
0 Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stomrwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
0 Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
0 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 appli ation for permit(s).
OWNER SIGNATURE \. Date: k0 I i q 10
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 inspectio .Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature:
Date: ID I i e( 0 6
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 complian -with the Je erson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable respo$s silky for 1$6 in! t isnd corn'lying with the ESA. The Applicant has read this disclai er and igns and dates it below.
Signature: c D " I • \ ' Date: ‘0 ( 0 �Q-6
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc ll
11, •
OWNER BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
7cr"t l.ixd‘ow ASObex.1o►4tS 1 WC—. (36 )4? i—24 o 1 ea )43-1-25 2.7.,
MAILING ADDRESS: --14:::›" p-„t1,,jeY t-o.ne,mot-4 l_ FMAIL:
CONTRACTOR'S LICENSE WA 418310.SS WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
X New ,M' Wood Existing: 4 Sewer
❑ Addition ri Steel Proposed: .Z-. Bank ❑ Community System
LI Alteration/Remodel CI Concrete Total: Z. Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: CA Setback: ❑ Private well a Two Party
Type of Heat: Proposed: • 3 ,r Public
\\e.oaX 1�rnP Total: 3 Name of System:oWs.i
If this is a Commercial Protect 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 I 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:
i Underground Tank )-Above ground Tank Size of Propane Tank: 120 e3c3...)\o.1
i Heat Stove i Cook Stove i Woodstove �Fireplace Insert i Hot Water Tank i Pellet Stove i 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 Office Use Only
Current Proposed Amount
Main Floor Consistency Review:
21 '7— a3.3ao3 07
2"u Floor Base fee:
3rd Floor Additional Section:
Mezzanine: Plan Check fee: .y
)a3q.a0 I I a
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee: a212L
)
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Garage/Carport
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