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HomeMy WebLinkAboutBLD2006-00688 4.1 UILDING PERMIT APP LICAAN MLA06-00658` Jefferson County Department of Community Development Review Type:I 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00688 SITE ADDRESS: 9103 SR 20 Received Date: 12/6/2006 OWNER: JAMES E REYNOLDS JR ROBIN REYNOLDS PHONE: (360) 385-7468 91 MARINE VIEW PLACE PORT TOWNSEND WA 98368 SUBDIVISION: PHILLIPS BAY VIEW ADDITION Block: 31 Lot: 4,5,6 PARCEL NUMBER: 986703104 Section: 16 Township: 30 N Range: 01 W CONTRACTOR: HI-LINE HOMES 11306 62ND AVE E PHONE: 253-840-1849 PUYALLUP WA 98373 Contractor's License HILINH*981BT Expires 2/10/2008 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW SFR WITH COVERED PORCH TYPE OF WORK RES SQUARE FOOTAGE=: TYPE OF IMP NEW VALUATION 191,561.00 MAIN: 2,112 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 OCCUPANCY: HEAT BASE: R-3 HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: 5N OTHER: CONST TYPE: GARAGE: SHORELINE: DECK: 96 SETBACK: SEWAGE DISPOSAL: CON BANK HEIGHT: WATER SYSTEM: CITY BEDROOMS: BATHROOMS: Exist: Exist: Prop: 4 Prop: 2 Total: 4 Total: 2 Routing Date: Type Amount Paid Bv: Date: Receipt: Approved/Date $1,508.95 KAS 12/06/06 86921 A P P R O V E D Plan Check $980.82 KAS 12/06/06 86921 State Building Code $4.50 KAS 12/06/06 86921 Potable Water Application $55.00 KAS 12/06/06 86921 JUN 2007 Total: $2,549.27 Jefferson County Planning & Building Department ii Jefferson County Building lision Permit NIL BLD06-00688 BUILDING PERMIT INSPECTION APPROVALS Applicant: REYNOLDS JR 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 ✓ Erosion Control Foundation Footing II/ZR(6( OTC. Footing Drains Foundation Stem Wall 1/44/0 g Underground Plumbing plA Under Floor Framing I Straps(hold downs) iNtik air-, 1 L.2y_� Ext. Shear Wall Nailing l l O_-(f6 W Rough-in PlumbingL 1\1'a��`�'l 2//3/Dir noing3-ric w�rr�,c amx Ale- 13 01 041- Framing gs{/GT 2// Blocking Vi/AO Airseal2/11 // Insulation:Walls _ /5;, Insulation:Floors Ar Insulation:Ceiling Int. Shear Wall Nailing e Wallboard Nailing 3�5"9 ) Drywell/Alt Drainage Address Posted FINAL INSPECTION `I 16 91--' FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR ! • CONDITIONS for Building Permit# :BLD06-00688 1.) The application was reviewed by the Jefferson County Department of Community Development staff on December 18, 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: Susceptible Aquifer Recharge Areas and Special Aquifer Recharge Protection Areas. 2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3) All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit (4)All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit (5) Unsewered Planned Rural Residential Developments (6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 5.) 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. 6.) The applicant is proposing to create or add 2208 square feet of impervious surface and 3612 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 7.) A Medium 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. 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 site plan as submitted with the building permit application on December 6, 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 p-ld-fps, shall be resubmitted for review and approval by Jefferson County Department of Community Development. 10.) This approval is for a single family residence 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 vets shall be stored on any lot unless totallyened 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 setbacks from the edges of Reynolds Rd right-of-way and Elizabeth St right-of-way are 20 ft. Minimum side and rear setbcaks are 5 ft. 14.) 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. 15.) 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. 16.) Maximum lot coverage is not to exceed 25%. 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.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 19.) A septic permit (SEP06-00480) was approved on December 27, 2006 for a system of 480 gallons per day 20.) Reynolds Rd (P634) is a private Rd. The road approach is existing and an address of 91 Reynolds Rd has been assigned to the parcel. 21.) This parcel was created through the Phillips Bay View Addition to Port Townsend, filed of record June 7, 1890 as amended ans recorded on December 26, 1990 under AFN 337103 with Jefferson County Auditor's office. 22.) The proposal is to develop across separate parcels. Setback requirements will not allow for the development to span over lot lines. For the purpose of meeting bulk and dimensional requirements and minimum land area, a Declaration of Restrictive Covenant has been recorded under AFN 518903. 23.) A minimum of two (2) on-site parking spaces are required for the single family residence. II • • JEFFERSONa.littfrilk-cll cb iRJE COUNTY Al 44,1 ► DEPARTMENT OF COMMUNITY DEVELOPMENT ,".J I l'.uti4t C '' ' 621 Sheridan Street • Port Townsend •Washington 98368 i 360/379-4450 • 360/379-4451 Fax jrrf 11 http://www.co.Jefferson.wa.us/commdeveiopmenU E t" a ' � �u STORMWATER SITE PLAN SUBMITTAL TEMPLATE IMLA# 0(0 VP) PROJECT/APPLICANT NAME: •�-- J Iq.rY1 t'.5 J.% ��e.c,�n at> r 1(� I 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. "! f / L�I�h f fo? p,i 7 L,0 J 14-L ` A. /'/l.vt$7. n ' "r'.-' K Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. F71-3 r 41,/i'111 J L L4.. - rT2Z .a - 3. Describe the existing vegetation. Indicate native vegetation areas on the site ma PPR°V�D ,JA,g,.z ,-.u�,, .� ,ay,, ,),; &Leo a.P. &1 T 0 rokwAT-R p4 4. Describe the existing soils. Indicate soil type on the site map. 111 JUN - 4 2007 JEFFERSON COIJNTy DEPT. ('p�t UNt U LO ISVIL 5. Describe the existingsite hydrology i.e.,drainage;behavior of water on -gl�;�r rr�.AP ..t v ,_„ 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. t tileI rx.C.r i�r t, c=, 6. Describe any excess levels of noise generated by the proposed use or activity: IREC Y E1REV ) ....4,4,,,,,,ratted ,4 4,-7-77,, cl 0-K.4_€ , .IFFFI-M'llo .►111111+ stormwater site plan template—rev.10/1/2003 5 , 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.). �/Z.c<lo2 # r-.*- ,i. 1�(:e.t�tC1 i �- r : d� it, fi .c � 2,1 ,'�^1 I:1-4 G7Q, 1 b L,'9G .-, ,PA. 01- cJ&i-f h,-7, t-A 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 G /L4 proposed facilities from existing facilities. '3 /-4, e'4 <GtL., �. r- ez: C/') y.Z2-t' ),gin/.r,1 er treatment s oposed 10. ' If the project requires the use of stormwater treatment facilities, nd d differentiate proposed facilities tfrom existing ffacilitiespr(Th s is for use,orr the'site. Locate these facilities on p normally for large"projects or projects that involve the potential for dispersion of contaminants.] , itl ? s S a 11. ''. Describe the performance goals and standards applicable to the project. A j,q RF(E v— 12. Describe the flow control system. 4 1 i ri AI / Nib,« i)EA' TT[) r _:, r r gcA� 7.5 . i9� it -.L1 Lw� d �s-� i,_� Jft tiJIt I,I1lll11l' liCI1 stormwater site plan template—rev.10/1/2003 I • • 13. Describe the water quality system. ) t N . 14. Describe the conveyance system analysis and design. 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. .4//r3✓.e 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform u lding Code. 17. Describe th,proposed surfacing material. 18. Describe meth for restoration of the site. ov..c -24:1,204 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.4AJ/l 20. List h a d include any special reports or studies conducted to prepare the Stormwater Site Plan. 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 re uirements,describe those conditions or restriction e. / jam' VP f) ff� n l I ,�� R E-CEINT,I) .IFFFFNIIEM I IUIlN►' a,''f' stormwater site plan template—rev.10/1/2003 , 7 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 wilt 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. - / �" // / - r f 0.4 �,'ram/ 64 USX X. tJ Aot, C.0 ��{'�� Ian c��n�/ aleet:::::cl'c/ � G PCc.t Cl' J � 2. `Es)?bli e,/-ef iructi Access. , AI 1-_--e c-x(C eALJ 1 I d..4,0e-tii z k.-..) ,..4&at. ....)“A 4 I r`c A ii 4,)-71e- Cfl%zc� �, b I('t/�.e�. /, f /�rcr� /' f1 / L✓A 61..„ 44A.M. .46// /ram (.44. ,i ii pe,ly 5`%I r 4 for r'.a a eil,a P Gl any , 3. Control Flow Rates. �f t r vu � �Q J 6, Js' V-r,P, d-r e- bar . 1 n6-44, po� CC L bt Q J br, A i to %m. l� �/4S4- 6)b r2w -o JC7l� t o1c//-A- ( I'"" in41ti.,, G,1.1_ (AAA,rv-prz,tftf Jinc,a-� - /�C Dre�. %I/ZabAIA. .a(/ /1//1Ax4 0 4vt-L iif)1 t r i4 fov 'cf C ciw- ) Arad,, 4. Install' Sediment Controls. /' ©f! Y �135f «d /lrc-t 1 ec,C-i pi tap_aA �r Ili_ tAie added'ed' Q 1 mt 0� Pitc;✓e�1 ( I e tAi b u^rn 4-0 Ae'elu zc �^.-1 L�vS;c•1 t. i I .ss 1s 10l c-�i a(. 5. Stabilize Soils.GulNu p u 4.4.,...,_t l .. 11 Ae(-e k,do l 1 //J 1 ;Ale cn fro W1� I0t ,,.J P4'42.I- rig eSs LiA"--LQ //,u-a.d ✓J p/�nZJ r` 6. Protect Slopes. F(crillo,r1,A 7. Protect Drain Inlets. �e2 X ECE71) 8 stormwater site plan template-rev.10/1/2003 Riff . /tl+ i i fiN i k i I'' / • 41/ 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. ez-• 9. Control Pollutants. / cltiresp r� aA,•al CktiDe D zve 0,0 vett 10. Control De-Watering(the act of pumpingnngroundwater or stormwater away from an active construction site). Amei y L I 11. Maintain Best Management Practices(j3MPs). Site da,! Cl /1 uv, 12. Manage the Project. I G� , ✓�( �+�- l�Y� 'v. ,DNA LO sr 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). 3. Environmentally Sensitive Areas. a. Description of environmentally sensit've areas that are on or adjacent to the sit=. (' " 1 ,4 4 lrb stonnwater site plan template—rev.10/12003 I F f Ff N,1'I I l 1 9 b. Description of special requirements fo Nworking in or near environmentally sensitive areas. I, 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,permeabili ,depth,texture,soil structure). / A �� 1 LAZill-kl" ' 5. Construction Phasing. a. Construction sequence /J /.j "', (i�i 61 r 1.z1,? i�rA e L /]LIAK4^ D .-e,F,. G<J`C LPL%L -I b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. —"''�{ Provide a proposed construction schedule. y �t y J,� G� y` L J/'-i- A fii-- i 4,,..,-fa i .r C....1.t'-tIv Z . /fl 74ii 4 > H. Wet Season Construction Activities. a. Proposed wet season construction activities. 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. / t', �tL �,�t-�#' /(.��ri (��(L�"� tif'�,-.�-U.4t..v,;:r 1�")-1 b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Design Calcyllaafio s on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. �/ // Ri, i_�"�, 4t 4)_ b. Diversions. . c. Waterways. nrr n "rinr, d. Runoff/Stormwater Det 'o. cuEca 10 stormwater site plan template-rev.10/12003 *too AI* • • Stormwater Site Plan Changes If the eigoer DCD wishes tor cnstructiion.nges orThe submittaons to l) shallhe ginally includepsubstiittu a pages Site Plan, de all proposed changes,shall be revised submitted to DCD prior to co supports the reason for the change. drawings showing any structural changes,and any other supporting information that explains and supp Final Corrected Plan Submittal MPs f the project included scoat titer cof conveyance systems,treatment nstruction management BMPs)the applicant shalllities,flow s submit a final corrected plan ("as-bunts")when the project is (not ple ed. Thonese htorm 9 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/ sr being made attest that hew i the full knowledge and consent of nformation provided herein is true d all correct to the best of my knowledge. I also certify that this application owners of the affected property. ,.„41 • -0 3----6) 6 (DATE) DOWNER OR AUTHORIZED RE RESENTA SIGNATURE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: • � JE( VIED EC ItYt01-k; •R nn ta� ., ,'x , IEff ti 1Jl� qiilNo iirn 12 stormwater site plan template—rev.10/1/2003 ��.g,SON c0� JEFFERSON OUNN ,k '��(�v� �`�� �� • ) , 4 DEPARTMENT OF COMMUNITY DEVELOPMENT .-. K1 621 Sheridan Street • Port Townsend •Washington 98368 DEC !� 360/379-4450 • 360/379-4451 Fax 2906 .ir P LztO www.co.jefferson.wa.us/commdevelopment CC ' Master Permit Application JEf(E �tI' ,(1U 1' D Project rir'I Description(include separate sheets as necessary): MLA: S)r) )e I Ck I Tax Parcel Number: ��t!p 7D�3 t'(� Property Size: S-e-UQ SQ (acres/square feet) Site Address and/or Directions to Property: "( j•t•` Property Owner(s)of Record: a C A,r O`` '"% �'t 1'i Telephone: ,fig S- Vi p " Fax: Mailing Address:_ ----_ email:AT r.,d,�,�,a ,i, , _ ,Y i,:•� , -_ Tit _� �s� 98�e -� r� - 'r, Applicant/Agent(if different from owner): 50 Telephone: Fax: Mailing Address: --------- email: What kind of Permit?(Check each box that applies) is/Puilding ❑ Demolition Permit ❑ Variance(Minor,Major or Reasonable Economic Use) Family 0 Conditional Use[C(a), C(d),or C]** 4Single 0 Discretionary"D"or Unnamed Use Classification Garage Attached/Detached (Manufactured Home ❑ Special Use(Essential Public Facilities)** ❑Modular ❑ Boundary Line Adjustment ❑ Commercial* 0 Short Plat** 0 Change of Use 0 Binding Site Plan** ❑Address 0 Long Plat** ❑Add ss 0 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** 0 Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration** ❑Shoreline Master Program Exemption/Permit Revisions** 0 Stormwater Management ❑ Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Substantial Development** 0 Temporary Use ❑ Shoreline Management Variance ❑Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑ Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment *Ma r-.uire a Pre—• ..iication Conference ** Please identify any other local, state or federal permits required for this proposal, if known:Conference I hereby designate DESIGNATION OF AGENT ilf to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE o Jr. /--"? 1 -# - & f.a Date:OF 4 r�', �� '. !f,„...„i By signing this ap. form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct his,her or it's kno edge. Any material falsehood or any omission of a material fad made by the owner/agent with respect to this applica to tion packet may result in this permit being null and void. the best of 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 solepurpose heview and any r • " ad later inspections.Access and right of en to this ro hours. trY P perty shall be requested and shall occur only during re r business of t lion Signature: k Ad/ , I I Amy i�j Date: •- ! ' Lit C' The attractions Applicant will undertake as a result of the issuance of this permit may negatively impact u or endangered species and could lead to a potential lake"of an endangeredpeces P as those terms are defined in n the h fone er moree law known as t e"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions thatwill beeundertake 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 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-tran able responsib'li rtt�f r adherin a e9 g your Signature: complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Date: } :� -l'''/ , G:\Peron ter\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 they are not licensed contractors and that they will be assu ' the responsibilie General Contractor for the proposed project. i Date: / Z `'•i �' Signature: PHONE: FAx. GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: ( ) ( ) k 1 eve o AI EML: MAILING ADDRESS: EM IL: CONTRACTORS LICENSE NS NUMBER NUMBER: PHONE ( ) FAX:( ) ARCHITECT/ENGINEER: EMAIL MAILING ADDRESS: Shoreline: Type of Sewage Disposal: Project Type: -FraW Type: Bathrooms: � e�Sewer Existing: Bank ❑ Community System LiNew Proposed: ❑ Addition Steel Total: -�� He1'Qt)ty� �Individual System ❑ Alteration/Remodel ❑ Concrete j"�� 1t SEP Permit# ❑ Repairmo ❑ Masonry Bedrooms: Water Supply: ❑ nthP� Setback: ❑ Private well ❑ Two Party ❑ Demolition t r Existing: L_ : ' Proposed: _ 1�- Public y I J f Type of Heat: Total: • Na ae of S stem: If this is a Commercial Project you must answer the fProponspecl.-- Number of ADA Parking Spaces: Number of Parking Spaces: Current: Proposed Number of occupants(includes owners,tenants,employees,etc) Current Will you have Food Srvice? Yes / No IBC Occupancy: — IBC Type of construction: If this is a Pro ane Tank and/or liance Installation rmrt Size f Propane Tank all items below that a 1 : ❑ Underground Tank 0Above ground Tank ❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove ❑ Other Is this a liance bein installed in a Manufactured I Mobile Home? Yes / No s,all When applying for a permit to Install a propane tank you must also submit a site it plan showing g all of the septic building components,prope� gs lines,tank location and size,distances from the propan e tank to all property includin r the reserve area. S•uare Foota!a fot.Office Use Only c-1.1- _P, 4. Amount •( Current Pro•osed Consistency Review: Main Floor 1 1 A-_-- 1`;, 5 t, 55 r- , �y i i Floor 110 2'• Base fee:MINIMI i . Additional Section: ::-------.._. 3' Floor • 11111111111111 Plan Check fee: (I��. Mezzanine: I✓. U, State Surcharge fee: j r ` ' t Heated Basement t Pot Water Review fee: .✓ Unheated Basement 911/Rd Approach fee: f�` 1 k y ; ` , Other Unheated Garage/Carport TOTAL: $ 1 Decks Receipt Number: �` D I r} / Cash/Check Number: c Other `I 6 I IOa. t � p ~N •r. Can e r& ESTIMATED COST(REQUIRED) Date: .Fair market value of all labor and materials foundation finislr - =' _ ID mum InOials: 6 G:\permitCenter\FORMS\DRD FORMS\Master Permit APpltc tion 7-8-04.doc >O OD :'J O‘ (JI .la '1)W N _. A (n-10 cvTI GlZ m-v (no(n v 80 (nv r� CcmmmD O-0a2 ZO mp 20 mmm m �� ,�-iC0 �_ X w0C-"p AO�m 7mv2H pDc� �jOm Sm c� T or-i mm Da Ho ZCO Z nA c)c6� O T' C7 .�--{ mZmc>2 Sa v A rZ c,m c> Z H (n O Z r"r' ,mod m ---II �wZDI cZii07n0vp ZT vm D(Zn> m m› oma D C !'7 4 o O m ri 2 r-1 r ' zVraZ� m=�'m2mam0m Hmpv O Z oOcD tar' ba (� v'7o v ZA7vA 4' C`-= '1 -= Z-i DC °r ?Hoyy ? 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