HomeMy WebLinkAboutBLD2006-00661 • BUILDING PERMIT •
• Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00661 Received Date: 11/17/2006
SITE ADDRESS: 90 WEST MATS MATS LN Issue Date 1/30/2007
PORT LUDLOW, 98365 Expiration Date 1/30/2008
OWNER: JENS W COPPENRATH PHONE: (360) 385-0694
KARLE L COPPENRATH
PO BOX 408
PORT TOWNSEND WA 98368-0408
SUBDIVISION: Block: Lot: T 71+
PARCEL NUMBER: 821042083 Section: 4 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW SFR
ALSO U/G 500 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 308,065.00 MAIN: 1,410
CODE EDITION: 2003 ADD'L: 1,410 HEAT TYPE: PRO
OCCUPANCY: R_3 HEAT BASE: 494 HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: 5N OTHER:
GARAGE: SHORELINE:
CONST TYPE: SETBACK: 30
DECK: 468
BANK HEIGHT: 8
SEWAGE DISPOSAL: CON
WATER SYSTEM: PWELL Type Amount Paid By: Date: Receipt:
BEDROOMS: BATHROOMS: Permit $2,164.15 KAS 11/17/06 86778
Exist: Exist: Plan Check $1,406.70 KAS 11/17/06 86778
Prop: 1 Prop: 2 State Building Code $4.50 KAS 11/17/06 86778
Total: 1 Total: 2 Potable Water Application $55.00 KAS 11/17/06 86778
Total: $3,630.35
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
4111 •
CONDITIONS for Building Permit# :BLD06-00661
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on November 28, 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; coastal SIPZ.
2.) 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.
3.) 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.
4.) 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.
5.) 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.
6.) 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.
MANDATORY MEASURES FOR COSTAL SIPZ: •
1. Fot 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.
8.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
9.) The applicant is proposing to create or add 1992 square feet of impervious surface and
1992 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington to control stormwater, erosion and sediment during construction. BMPs shall
address permanent measures to stabilize soil exposed during construction, and in the
design and operation of stormwater and drainage control systems.
10.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements#1 through #12 of the Department of Ecology's Stormwater Management
Manual for Western Washington to control stormwater, erosion and sediment during
construction. BMPs shall address permanent measures to stabilize soil exposed during
construction, and in the design and operation of stormwater and drainage control systems.
11.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
12.) 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).
13.) The site plan as submitted with the building permit application on November 17, 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 November 28, 2006 shall be
resubmitted for review and approval by Jefferson County Department of Community
Development.
14.) This approval is for a single family residence with 500 gallon under-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.
15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
16.) 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.
17.) Minimum setback from West Mats Mats Lane right-of-way shall be 20 feet. Minimum side
yard setbacks shall be 5 feet. Minimum setback from Ordinary High Water Mark shall be
30 feet.
18.) 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.
19.) Lighting fixtures shall be designed•hooded to prevent the light source from be
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.
20.) 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.
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 building height is not to exceed 35 feet.
23.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
24.) These parcels have been designated as Rural Residential 1:5 under the Jefferson County
Comprehensive Plan Land Use Map effective August 28, 1998.
25.) The parcel is served by an individual on-site well.
26.) An address of 90 West Mats Mats Lane, Port Ludlow has been assigned to the parcel.
West Mats Mats Lane is a private road (P186).
27.) A septic permit (SEP88-0042) was finaled on January 23, 1989. A SPAAD was finaled on
November 17, 2006 for submittal of this SFR application.
28.) A Declaration of Restrictive Covenant was recorded on September 23, 2002 under AFN
460309 to bind parcels 821 042 082 and 821 042 083 together to allow development to
span lot lines.
29.) A Declaration of Restrictive Covenant was recorded on January 26, 2007 under AFN
519880. The purpose of the Covenant is to notify potential purchasers that the on-site
sewage disposal system is limited in capacity to one (1) bedroom.
OUILDING PERMIT APPLICA'� N MLA06-00635
Jefferson County Department of Community Development Review Type:I
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00661
Received Date: 11/17/2006
SITE ADDRESS:
90 WEST MATS MATS LN
PORT LUDLOW, 98365
OWNER: JENS W COPPENRATH
KARLE L COPPENRATH PHONE: (360) 385-0694
PO BOX 408
PORT TOWNSEND WA 98368-0408
SUBDIVISION:
Block: Lot: T 71+
PARCEL NUMBER: 821042083
Section: 4 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER
PHONE:
REPRESENTATIVE:
PHONE:
PROJECT DESCRIPTIOr NEW SFR
ALSO U/G 500 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE
TYPE OF IMP NEW
VALUATION 308,065.00 MAIN: 1,410
ADD'L: 1,410 HEAT TYPE: PRO
CODE EDITION: 2003
HEAT BASE: 494 HEAT TYPE:
OCCUPANCY: R_3
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: 5N OTHER:
CONST TYPE: GARAGE: SHORELINE:
DECK: 468 SETBACK: 30
SEWAGE DISPOSAL: CON BANK HEIGHT: 8
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 1 Prop: 2
Total: 1 Total: 2
Routing Date:
1112) i0(06 -
Type Amount Paid By: Date: Receipt:
Permit Approved/Date
$2,164.15 KAS 11/17/06 86778 , I
Plan Check $1,406.70 KAS 11/17/06 86778 �` �,
State Building Code
$4.50 KAS 11/17/06 86778 JAN 3O 2007
Potable Water Application $55.00 KAS 11/17/06 86778
Total: $3,630.35
AMMIIIIIIIN
11111 Jefferson County Building Divi;, on
Permit Number. BLD06-00661
Applicant: RATH
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2 International03PEN
To schedule inspections, call (360)379-4455 no later than 7 00 AM the day of the inspection. Builu�ng Codes
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
- -------- - -
A5
Erosion C mR S'r2i4444 ;Y owwe
S Lr F
Foundation Footing -
gi13/07
Footing Drains . , , Ave
MI 1
Foundation Stem Wall1,11111 ak
O 2407
Underground Plumbing
Under Floor Framing
f/ q a/ MEM eft_
Straps(hold downs)
Ext. Shear Wall Nailing 40,
Rough-in Plumbing "
YAW& Aloes OK / I• cr-7/Y'
Framing
Blocking
/72-0 j IMMO
Airseal
nalliM111111
Insulation: Walls
Insulation: Floors
Insulation:Ceiling IIMMIIIIIIIII
Int. Shear Wall Nailing
Wallboard Nailing —
I- // 0 f an..
Gas Line: Interior
MIIIMIIIII
Gas Line: Exterior
Propane Tank .r�, i . /iII4IVi4II
07
Heat/Chimney Clearance r
Drywell/Alt Drainage
rof MIN
Address Posted
this -R LA6 /,usia- //,7 08 17./ o,e
NYD,eawc Znv€S ///7/66 el1V 6<
FINAL INSOECTION / 0
l9_1� bD'3p;:4S W '&Lhi2 i 61-f-n
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
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r °� JEFFERSON COUNTY 1,
►. DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 9836 j ' pr an
4, �O 360/379-4450 • 360/379-4451 Fax �'ds ;fl ;o �;IBM
http://www.co.jefferson.wa.us/commdevelopment/ �'
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
IMLA# Q( (CD: 5 PROJECT/APPLICANT NAME:
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.
Existing Conditions Summary f F �� ('
2. Describe the exi1. sting topography. indicates contours on the site map. JE" " ��� � ��" �� �`'
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.
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:
STORMWATER PLAN
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Stormwa r, Mc j
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stortnwater site plan template—rev.1N1/2003 SIGNATUR ++JJ�{ `�`5 )
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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.
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.).
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.
g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual) or, if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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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 facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
11. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system.
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. t [�
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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.
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17. Describe the proposed surfacing material.
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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.
20. List here and include any special reports� or studies conducted to prepare the Stormwater Site Plan.
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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
7
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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.
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2. Establish Construction Access.r Cc `
3. Control Flow Rates.
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4. Install Sediment Controls.
5. Stabilize Soils.
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6. Protect Slopes.
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7. Protect Drain Inlets. fr. 1 ' r 1_, .
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stormwater site plan template-rev.10/1/2003
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12 Required Elements—Construction SWPPP(continued) <*
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8. Stabilize Channels and Outlets.
-
9. Control Pollutants.
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
12. Manage the Project.
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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).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). (A/C C1
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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.
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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 •\A iffk
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). �� r F +
I. Provide a proposed construction schedule \ti�� W ��; ,� `°-, ) .r11\t i `'A 1
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities. S
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b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
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)b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. �1\ I `n
c. Waterways.
d. Runoff/Stormwater Detention Calculations
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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 e
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
Bysi in t e C strtIction SWPPP works eet, I as the applicant own isr beingst that he i the infuformation(
k provided andr cons sent strueof alld
g �erti that this application
correct to th be,t of my knowledge. I also fy PP
owners of th aff ed property.
� (DATE)
(LANDOWNER IFIAUORIZ D REP43E ENTATIV SIGfTU
THIS •SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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storrnwater site plan template—rev.10/12003
•�„gON c III
4 O JEFFERSON COUNTY
,� DEPARTMENT OF COMMUNITY DEVELOPMENT
~' ` `4 M 621 Sheridan Street • Port Townsend •Washington 98368
4. may, 360/379-4450 • 360/379-4451 Fax
.qb, tp www.co.jefferson.wa.us/commdevelopment
bTING
Master Permit Application MLA: 0(c) - (P '5
Project Description(include separate sheets as necess
'RR s%Clete \ we (1 ,'L.16
Tax Parcel SZ I 04 2 0 V2 / O. '3 Property
Number: Size: 1 g
Co
(acres/square feet)
Site Address and/or Directions to Property: 10 Ii W e,j,F ha-S t-t4s t,t,i
Property Owner(s)of Record: a t-t•)S •t- )L,a.Q2 L$. Co P 'E v. ,ce2p1--7 u
Telephone: 3(t O g gS OG14- Fax: 3$S O(0 al f email: (c�
Mailing Address: PO l3 OJC (kog I P p r- To L.,.)to 5.-.4..cA , Cr‘..) t ) el e s ( 8
Applicant/Agent(if different from owner): (1
Telephone: Fax: G� email:
Mailing Address:
Mat kind of Permit?(Check each box that applies)
rPgwlding ID " n li Variance(Minor,Major or Reasonable Economic Use)
d Demolition Permit R 1 �� it In,!� Conditional Use[C(a),C(d),or C]**
d Single Family Discretionary"D"or Unnamed Use Classification
Q Garage Attached/Detached °Special Use(Essential Public Facilities)**
El Manufactured Home -- °Boundary Line Adjustment
d Modular °Short Plat**
0 Commercial* °Binding Site Plan**
Qhange of Use °Long Plat**
Q_address i Road Rs isi'(', i �'�'nl I , °Planned Rural Residential Development(PRRD)/Amendments**
Propane I F�IIUUTI�rltdUtlftf- i ❑Plat Vacation/Alteration** p ( )
❑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 OComprehensive Plan/UDC/Land Use District Map Amendment
OWireless Telecommunication* °Jefferson County Shoreline Master Program Amendment
❑Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference
**Requires aPre-App/ication 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 I
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,i..emni and ho h- les Jefferson County-.ainst all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which ma ' any way.ccru:a. nst J e erson County as a -.ult of or in consequence of the granting of this permit.
I further agree to . ovide access.nd ig of en to Jeffer e. County a • its employees,representatives or agents for the sole purpose of application
review and any r quired later ins,e or . S access and rig • :• .APwill be assumed unless the applicant informs the County in writing at the
time of the appli .lion that he orb .nt .ri fnotice.
Signature: / 4/.. 4 Date: 10 — 2 — ZoOG
rimyThe action or a.' ,, s Ap.' .,'t �r will u "'. s- result of the i : an :of this permit may negatively impact upon one or more threatened or
endangered species and ./.d lead o a .otenti. "take"of an -ndanger•d species as those terms are defined in the federal law known as the
"Endangered pecies Act"• "ES• Jr erso ounty mak-s no assu :nces to the applicant that the actions that will be undertaken because this
permit has b:en issued will of vi.a -the -•. A y indivi•ual,grou.or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)eve I you are i, •m yV: ce ' e /e on C.• de - .• ent code.The Applicant acknowledges that he,she or it holds individual
and non-transfera. - -s,..: 'ill•• • -d•. i o .'. :• p r 77 th e ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ,
Date: (0- 2 — 700 C,
D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc
0 •
( BUILDER STATEMENT
The signer of thi stateme t doe her y ify that they are‘the 'Hers of the parcel referenced herein,that they are not licensed contractors and that
they will be as ming the espo lb" ty o h eneral Contractbr,f r the proposed project.
Signature: Date: 10 r 2 — lz l cn
GENERAL CO TO R MANUFATURE OME INSTALLER: PHONE: i 3v' Iron Y 1 1\
( )
: INN _", (x..4JL) :1 i II
MAILING ADDRESS: EMAIL: l
CONTRACTOR'S LICENSE WAINS 4 1 '
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) r FAX:( )
MAILING ADDRESS: EMAIL -rty``I�p i +) gt @ p
Project Type: Frame Type: Bathrooms: Shoreline: LLLL'ryppeeYYor be a e Disposal:
La'New Er Wood Existing: 0 Sewer
❑ Addition 0 Steel Proposed: Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: 2— Height:/ 0 Individual System
8
❑ Repair ❑ Masonry SEP Permit# Re LI Z
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: Private well 0 Two Party
Type of Heat: Proposed: ( 0 Public
C.-PCB _.&Okr-� Total: 1 Name of System:
0
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:
nderground Tank 0 Above ground Tank Size of Propane Tank: SO 0 A.(,
❑Heat Stove 0 Cook Stove 0 Woodstove Fireplace Insert 0 Hot Water Tank 0 Pellet Stove Di Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / l�o
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 Current Proposed For Office Use Only Amount Revision
Main Floor Heated _ 1 i({' (O i o,i_rig. i EH Bid App Review:f. / t3
veti
2' Floor Heated 3 Consistency Review: l!?
Other Heated Base fee: a 1�A i'
Mezzanine Additional Section:
Heated Basement 49 T t- q^+3�a.' Plan Check fee: 1 ` 9 0� .'1°
Unheated Basement `� State Surcharge fee: 4y40
Other Unheated Pot Water Review fee: .96
Garage/Carport SUBTOTAL 2 ,n 03 3
Decks 4 It Ov 1 L(p 911/Rd Approach fee: v 0
Other TOTAL: $
30? o(o4 R ceipt Number: toll 'WI` • ash/Check Number: UJ
51L-Cr
ESTIMATED COST(REQUIRED) Date: tt/
.Fair market value of all I bor and materials foundation to finish J L/ 1 !) e
'-d K. Initials: !
D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc
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