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HomeMy WebLinkAboutBLD2006-00712 06 IJ ILDING PERMIT APPLICA1 N MRL Review Ty 676 Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00712 Received Date: 12/21/2006 SITE ADDRESS: 23 RIVERDALE DR QUILCENE, 98376 OWNER: ROBERTUS VANDEWEGHE PHONE: 360-765-0756 JACOBA VANDEWEGHE 345 HIDDENDALE DR QUILCENE WA 98376 HIDDENDALE TRACTS ADDITION SUBDIVISION: Block: 3 Lot: 16 PARCEL NUMBER: 959400316 Section: 27 Township: 27 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI NSFR W/ATT GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,512 VALUATION 125,000.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: 5N GARAGE: 350 SHORELINE: CONST TYPE: DECK: 32 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: _., l a aa0C0 Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,133.75 LYK 12/21/06 87023 `,Plan Check $736.94 LYK 12/21/06 87023 � � L L �',�" t' _n State Building Code $4.50 LYK 12/21/06 87023 JAN ,a2007 Potable Water Application $55.00 LYK 12/21/06 87023 Total: $1,930.19 afiGIV.KiiGCntfVEMi1111 • � CONDITIONS for Building Permit# :BLD06-00712 1.) PRIOR TO SCHEDULING A FINAL BUILDING INSPECTION THE OWNER SHALL SUBMIT AN ORIGINAL LETTER FROM KUNZ BIOLOGICAL CONSULTING STATING THE PLANTINGS HAVE BEEN COMPLETED AND COMPLY WITH THE APPROVED PLANTING PLAN. THE LETTER SHALL ALSO STATE THE PROJECT COMPLIES WITH THE RECOMMENDATIONS AND CONDITIONS OF THE REVISED PRIORITY HABITAT AND SPECIES MANAGEMENT PLAN DATED OCTOBER 15, 2003. 2.) The applicant shall comply with all conditions and recommendations identified in the Revised Priority Habitat and Species Management Plan prepared by Kunz Biological Consulting dated October 15, 2003 and received November 6, 2003. A copy of the report is available at the Jefferson County Department of Community Development (MLA03-00292). 3.) The applicant shall adhere to the planting plan prepared by Ernest Harrell received December 3, 2003. The plantings shall be completed prior to a final building inspection. 4.) A permanent physical separation along the boundary of the streamside 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.) Streamside 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 be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer- Do Not Remove or Alter Existing Vegetation." 6.) An encroachment into the streamside buffer of five (5) feet shall be allowed for construction activities and routine maintenance and repair of the single family residence with attached garage. 7.) Setback from Riverdale Dr. right-of-way is no less than 20 ft., side and rear setbacks are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more restrictive setback shall apply. 8.) The building height is not to exceed 35 feet. 9.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 10.) No appurtenant structures such as decks, sheds or stairways shall be allowed within the 69-foot streamside buffer. 11.) The property owner, applicant or subsequent property owner, shall advise all contractors and subcontractors of these conditions. 12.) The road approach permit (RAP03-00120) must be inspected and finalled by the Jefferson County Department of Public Works prior to the final inspection/certificate of occupancy of this residence. Contact the Department of Public Works at 360-385-9160 for the final road approach inspection. 13.) The application was reviewed by the Jefferson County Department of Community Development staff on December 27, 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, the following ESAs were confirmed to be present on the subject property: Shoreline Designation - Conservancy, Big Quilcene River(Type 1 Stream), Spotted Owl Habitat, Harlequin Duck Habitat, Wetlands (mapped along river), Seismic Hazard Area, Erosion Area, Susceptible Aquifer Recharge Area (SUSC). 14.) 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. 15.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 16.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 17.) A Type 1 Stream (Fish and Wildlinabitat Area) has been identified on the suit property. A variance application from the standard streamside setback and review for impacts to fish &wildlife habitat was reviewed under MLA03-00511/ZONO3-00048. The stream will require a setback of 69-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 18.) Buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 19.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis), Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar (Thuja Plicata), and Western Hemlock (Tsuga Heterophylla). Among native tree species which may be used includes: Vine Maple (Acer Circinatum), Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa), Bitter Cherry(Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara (Rhamnus Purshiana), Pacific Willow (Saliz Lasiandra), and Scouler's Willow (Saliz Scouleriana). Among the native shrub species which may be used are: Sevice-Berry(Amalanchier Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark (Physocarpus Capitus), Red Flowering Currant (Ribes Sanguineum), Wild Rose (Rosa Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry (Sambucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry (Vaccinium Parvifolium). 20.) All construction activities shall not encroach upon the buffer. This includes the storage or preparation of materials. 21.) 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. 22.) Per the submitted flood plain investigation by Clark Land Office July 1, 2003, the buildable area proposed is located outside of the flood plain. 23.) A request to vary from the standard streamside buffer of 150 feet and maintain a buffer of 69 feet was granted on December 30, 2003 under MLA03-00511. 24.) A minimum of two (2) on-site parking spaces are required for the single family residence. 25.) This parcel is designated Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 26.) The parcel was established on July 9, 1965 through the Hiddendale Tracts Addition subdivision as recorded under Auditor's File Number 184317, Volume 4 of Long Plats, pages 71-72. 27.) The revised site plan as submitted on January 2, 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 January 4, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 28.) 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. 29.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 30.) Not more than 2 unlicensed vehicshall be stored on any lot unless totally sited 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. 31.) The applicant is proposing to create or add 2, 300 square feet of impervious surface and 2,600 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. 32.) A stormwater 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. 33.) 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. 34.) Riverdale Rd. (C300109) is a county local access road. A road approach (RAP03-00120) was approved on January 14, 2004 and an address of 23 Riverdale Dr. has been assigned to the parcel. • Jefferson County Building Division Permit Numbe,: BLD06-00712 Applicant: VANDEWEGHE 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 Erosion Control 2/23lo7 JkflA L xir6 NTuub+ QOLutm NODSF bove Foundation Footing 07 Footing Drains 1 r Foundation Stem Wall Underground Plumbing Under Floor Framing 2/23/0 �y Straps(hold downs) Ext. Shear Wall Nailing 511,5) 61 Rough in Plumbing Est C(.2) Framing _ -D"7 Tri, Airseal Insulation:Walls 51/0 Insulation: Floors ✓✓� / 7/3/0 Insulation: Ceiling y3/0/ Int. Shear Wall Nailing Wallboard Nailing /,-A - 0 .c01 Gas Line: Interior Gas Line: Exterior +,J/A Propane Tank N/A Heat/Chimney Clearance PZ, ,,n Drywell/Alt Drainage 7/3/57 Address Posted n/ -7/3/C77 FINAL INSPECTION 7/Y/07 1/ LEA( -Por C 4 FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR Note: For elevations etc, see Appd Site Plan 12/30/2003 MLA03-002Z0NO3-00048 Big Quilcene River — _ _ _ _ordinary "T Rs Elk 1.4 li t high water mark ___ ___-— ,..i ( •,,, ) I 63.93' I rj 0 2 2007 Reduced river buffer `O , II as per ZONO3-00048 or II MOOW(i1,1► MLA03-00292, subject to Revised Priority i 0 North Habitat& Species Management Plan by Kuntz 10/15/2003 and I Planting Plan by Harrell I 1 12/3/2003. I �.. (-,1 I I N connection of 0 1 1 downspouts to drywell o I I � o� 1 I a.CCS rn 1 69' setback from river po PERMIT # Bill o0 06 _ 71 2 connection of o downspouts to drywell n 1512 sqft � JEFFERSON COUNTY BCD \, 2 bedroom residence water line , and garage _� sewer —�- 6' \\\ community water line hook-up septic —� i CD tanks ---- -- overhead power& hnne low.- . SITE PLAN v drain field ' 18' � JAN - 4 _.) op reserve ;�_ • - . . drain field.,' .. / DEPT.OR < '•4,�1.., , • - -' oSIONATUR& "i r'i��.� >,.• yf W © G3 1' VG1ttrI1VC - c' Quilcene, WA 98376 2 dry wells 65.35, tax parcel: 959-400-316 4' diameter 5' deep i I Rob & Jacoba VandeWeghe (360)-765-0756 approximate edge of existing pavement Po Riverdale Drive ' SCALE 1 inch = 20 feet •SU,N , e ° JEFFERSON COUNTY z sl ` , ► DEPARTMENT OF COMMUNITY DEVELOPMENT a 621 Sheridan Street• Port Townsend • Washington 98368 O 360/379-4450 • 360/379-4451 Fax LINO http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# Up W t7p PROJECT/APPLICANT NAME: 1,'L UCt .as W fLtiL • 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. CO K c./12AN (D‘ P. "C)4 41Q AA ll-ti ge h"cittnte_ ..... pee p C(QpIct,.,, Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. 1i`4 i 1 /Mil y 1 Z.C.t . ‹ wec,. ‘1-.. —v-y2. X.L I( aco„� ` L o 1,e 4t,0.1(1iitT ice ( 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. ), )S , 1-vYkst 1:6'uN S cs. q L.)4 6'- cj,.g3 p 6,a, cC I A d d' ova J .t Att;c2 c9�ttr�AIL l 4. Describe the existing soils. Indicate soil type on the site map. t1 PkeetotN,tAQ.1 i.e.1 . ,^,,, 3114-- (0C(AN c (0am7 1FQH I d . 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. pa"5 L Q A Crc52.1 (I r Q)Jti a AQ-(Q,v%_A- 2KCsts0 kgcn1 A t 1(P\ w-61, - aA1kk Mt ucp . 6. Describe any excess levels of noise generated by the proposed use or activity: n a . fRAV # RlD — 712 JEFFERSON COUNTY 9CD stormwater site plan template.doc—rev.10/12/2003 t 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. L 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.). i 22>�s m� ���R� S 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. S TU QANumksirt., A9 AN. 1 e Gi eklAuz UJ.a b2 (fin J etAk A VI Ck e, t nth (zee kV e6, 4 e er)(o.&.-,) 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.] c2ti well Let rt to p fay. 11. Describe the performance goals and standards applicable to the project. ft 12. Describe the flow control system. stormwater site plan template.doc—rev.10/12/2003 6 • 0 EC 2 12006 13. Describe the water quality system. rA 14. Describe the conveyance system analysis and design.t Vklr( 15. Describe the source of fill material, physical characteristics of fill material, and deposition of excess material. h� int( Mtil�nxal terti;2eok. (?2ccat/cArA Aka-bt12;:a fin l 1t up �o2 ' cctt �n1( a>� t_ 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. g -4cku o' t.R`'�e`,t i 18. Describe methods for restoration of the site. PR-1,6,tt ch al pce..v a b-ti r( �: a I. /�.� 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. A ,cc 20. List here and include any special reports or studies cpnducted to prepare the Stormwater Site Plan. — RCA PA+:4n:, �i t`NI- a.�„A Sj s N.aKq �,(�,1 Sy GA A: kLAA2- I 0 1 f c/03 — e(a,,,tr l f( ( ,&_ b r 6 1(a itiaei t '2. 13/©3 , 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. 1 l0(dtlair �,Q4- 14- (4S ap/(i�Jl ` t6 1,f nkr, left c Re Rim.--A- S o‘ — 0. 122 stormwater site plan template.doc—rev.10/12/2003 7 . • • - ., „ r 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. f1 1 A CQQari..�n� l2Rec u�21d 6 it c,(2eq C R.P,1 . 2. Establish Construction Access. _ /J Visa I�-c.'ULIa&Q)J D/'lrp (}/�t i'Pb`l Co iA v. - ) 3. Control Flow Rates. b 1 4 5 (a l( 1 Lxti( ^�i l0 V'N a 7 teez-1-4“it 4 . Install Sediment Controls. kad4.�xc 7C� :.,‘ .54e -.t( fot.°1J — du1 Sii uo4 m, S £e ScccC�° 5. Stabilize Soils. CA,U"isM ci 0“\-1 Z Dfr ct Mkt 6. Protect Slopes. /4 a . 7. Protect Drain Inlets. n to . stormwater site plan template.doc-rev.10/12/2003 8 • • 12 Required Elements-Construction SWPPP(continued) 8. Stabilize Channels and Outlets. I/ i opt /dial (c1 A.Q0 elQ- - 9. Control Pollutants. A(cb _ 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. c 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). n �a . b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. A (G. stormwater site plan template doc—rev.10/12/2003 9 • S ` (fir I 6r\44+ b. Description of special requirements for working in or near environmentally sensitive areas.. Ada 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). A(a 5. Construction Phasing. a. Construction sequence .macC�,v�f A^ 'U.1Iw o-, _ ,/fikaMom' 4°4 — t S — W-e.f 1. b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). Provide a proposed construction schedule. II. Wet Season Construction Activities. a. Proposed wet season construc lon activities. cc, v, ( ftc,,,e1 ANCIACk `LPA.(A of 149 Le- 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. r `"t 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. r(\ b. Diversions. c. Waterways. d. Runoff/Stormwater Detention Calculations stormwater site plan template doc—rev.10/12/2003 10 0 I i Stormwater Site Plan Changes If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised drawings showing any structural changes, and any other supporting information that explains and supports the reason for the change. Final Corrected Plan Submittal If the project included construction of conveyance systems, treatment facilities, flow control facilities, or structural source control BMPs (not standard on-site stormwater management BMPs), the applicant shall submit a final corrected plan ("as-builts")when the project is completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as constructed. APPLICANT SIGNATURE By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected operty. (LANDOWNER OR AU H IZED REPRESENT ATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: stormwater site plan template.doc—rev.10/12/2003 12 III Mbath / �� c '' F �a � y �.n�> q� j.N O H n. o p,„4 V aYj,; co cn 4111 0 .! .,taa, fl .n.:.. Rx;iY f, „ •��'`^� ..tY ;i.,� . �'in k, ��:f.., S,''s ....e.. r r. GM \ LiAN ix 4a • co I: tL Y a. a o � Cr� CD o � CD fa. WC, igSON co& JEFFERSON COUNTY • DEPARTMENT OF COMMUNITY DEVELOPMENT "' 4,0 'C 621 Sheridan Street • Port Townsend • Washington 98368 4,14100, 360/379-4450 • 360/379-4451 Fax , `` '> ^f"'"3` ';: 11 (,1 1 LL V u! 14 p www.co.jefferson.wa.us/commdevelopment ZING Master Permit Application MLA: -(1 Project Description(include separate,sheets as necessary): , N S )V co 4\ ci.fTc.c 4a' i. Tax Parcel „ Property Number: Li _ Size: 7i (0,Oc''" Sci • (acres/square feet) Site Address and/or Directions to Property: 2 i ,I '- ( D \,-Q Property Owner(s)of Record: .1-1 ctv L- -)c, ,.,)4 cs I)r,,,, welt,. Telephone: 3 6,,-_: a 4 w i.- 1 E Fax: email: Ur'•1 , 1 Mailing Address: 3y I-t c.�.�t,?.�sl,,� �"irz �.,.l c. • U 3A t 6 -i r .r--'bs Applicant/Agent(if different from owner): t Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) Vtuilding i Variance(Minor, Major or Reasonable Economic Use) i Demolition Permit i Conditional Use[C(a), C(d), or C]** VSingle Famil +Discretionary"D"or Unnamed Use Classification VGarage ttache Detached +Special Use(Essential Public Facilities)** `Manufacture ome 1 Boundary Line Adjustment i Modular 1 Short Plat** i Commercial* i Binding Site Plan** i Change of Use f Long Plat** i Address i Road Approach i Planned Rural Residential Development(PRRD)/Amendments** t Propane t Plat Vacation/Alteration** i Allowed"Yes"Use Consistency Analysis i Shoreline Master Program Exemption/Permit Revisions** 1 Stormwater Management 1 Shoreline Management Substantial Development** I Site Plan Approval Advance Determination(SPAAD)* i Shoreline Management Variance i Temporary Use i Comprehensive Plan/UDC/Land Use District Map Amendment i Wireless Telecommunication* i Jefferson County Shoreline Master Program Amendment i 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 application for permit(s). ,(.�rh � � (/ �OWNER SIGNATURE ! Date: I L 1 1 (7( • By signing this application form,t 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 attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and righ 9f entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspection - Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she i nor notice. t { Signature: �/ _ Date: 12 I I I O The action or actions Applicant will tfridertake 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. ,,ny 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 J ferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable responsibility for adh i t qnd to, yigg.&cith the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: . Date: ( 'Z / /Is /rJ E., G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc • • BUILDER STATEMENT The signer of this statement doe ereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the respo sibOy of thneral Contractor for the proposed project. Signature: —"- Date: (% I r h (•>(-!.. GENERAL CONTRACTOR OVIANUFAC UT RED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: / LPL k Z ‘`,Z PHONE3(•:,., �� MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: EVNew L Wood Existing: a Sewer ❑ Addition ❑ Steel Proposed: 2 Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: 2 Height: A/Individual System ❑ Repair ❑ Masonry SEP Permit# --l^. —v 122, ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: 2, 1 Pr-Public iz �-G.r(4C. Total: .2 41 Name of System: :till Imo•,&11.i 2cn6 ; — j.- :(l,r),,,ct,....L- V: 4 If this is a Commercial Protect you must answer the following: c.::4 Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed [Br Occi 1pancy: IBC Type of construction: Wiii 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 i Above ground Tank Size of Propane Tank: I Heat Stove i Cook Stove i Woodstove I 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 Current Proposed For Office Use Only Amount Revision Main Floor Heated 0/3103,34, EH Bld App Review: av I t� 2 Floor Heated Consistency Review: '530.° Other Heated Base fee: Mezzanine Additional Section: Heated Basement Plan Check fee: 9 e Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: (�,r` Garage/Carport %Z.1.5D SUBTOTAL `--'(� Decks A, .�J �, Ir F } 911/Rd Approach fee: `'�Sn Other ►rll TOTAL: C$�D3 Receipt Number: 3 1 -703 Cash/Check Number: 4a l ESTIMATED COST(REQUIRED)—____ it i l 101 Date: �}�� •Fair market value of all laborandnraterial ndation to finish V{ 2 O Initials: i` G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc