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HomeMy WebLinkAboutBLD2007-00025 CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD07-00025 SITE ADDRESS: 3402 LELAND VALLEY RD WEST Issue Date: 02/16/2007 QUILCENE, 98376 Final Date: 3/24/2008 APPLICANT: LARRY G ROSS PHONE: 360-732-5026 KATHERINE J ROSS 742 PETERSON RD PORT TOWNSEND WA 98368-9781 SUBDIVISION: LORDS LAKE LOOP#2 SHORT PLAT Block: Lot: 2+ PARCEL NUMBER: 702024029 Section: 2 Township: 27 N Range: 02 W PROJECT DESCRIPTION: NEW M/H (2007 SKYLINE SILVER ADDITION) SERIAL#0262-W THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes ( no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 3/24/2008 I:\F_BLD_Occupa ncy.rpt 10/29/19 110 • MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD07-00025 Received Date: 1/30/2007 SITE ADDRESS: 3402 LELAND VALLEY RD WEST Issue Date: 2/16/2007 QUILCENE, 98376 APPLICANT: LARRY G ROSS KATHERINE J ROSS 742 PETERSON RD PORT TOWNSEND WA 983689781 SUBDIVISION: LORDS LAKE LOOP #2 SHORT PLAT Block: Lot: 2 PARCEL#: 702024029 Section: 2 Township: 27 N Range: 02 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: NEW M/H (2007 SKYLINE SILVER ADDITION) MAKE: SKYLINE YEAR: 2007 SIZE: SILVER THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 2/16/2008. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLYYOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, LAB or PADS USED)L <(lS 4,7 Stormwater FINAL Approval: Blocking/Plumbing: I(-t-01 Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 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 REVERSE BUILDING PERMIT APPLICA.N ML vy 034 Review T Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00025 Received Date: 1/30/2007 SITE ADDRESS: 3402 LELAND VALLEY RD WEST QUILCENE, 98376 OWNER: LARRY G ROSS PHONE: 360-732-5026 KATHERINE J ROSS 742 PETERSON RD PORT TOWNSEND WA 983689781 LORDS LAKE LOOP#2 SHORT PLAT SUBDIVISION: Block: Lot 2 PARCEL NUMBER: 702024029 Section: 2 Township: 27 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW M/H (2007 SKYLINE SILVER ADDITION) TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,456 VALUATION CODE EDITION: 2003 ADD'L: HEAT TYPE: EEE OCCUPANCY: HEAT BASE: HEAT TYPE: WOD OCCUPANCY: UNHEATED: # OF STORIES: CONST TYPE OTHER: SHORELINE: CONST TYPE GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: Type Amount Paid Bv: Date: Receipt: Approved/Date Manufactured Homes $163.00 LYK 01/30/07 87197 ppRcvEr Potable Water Application $58.00 LYK 01/30/07 87197 Total: $221.00 FEB 1(0 2007 Jefferson County Planning & Building Department ! • SPECIAL CONDITIONS CASE # BLD07-00025 1.) PRIOR TO OCCUPANCY FINAL APPROVAL OF SEPTIC SEP06-118 IS REQUIRED. 2.) a) MAINTAIN A MINIMUM OF 5' SETBACK FROM FOUNDATION TO SEPTIC TANK. b) 10' SEPARATION REQUIRED BETWEEN A WATER LINE AND ALL PORTIONS OF THE ONSITE SEWAGE SYSTEM; EFFLUENT TRANSPORT LINE, TANKS, TREATMENT AND DISPOSAL COMPONENTS. c) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC TANK, RESERVE & DRAINFIELD. d) NO CURTAIN OR FOOTING DRAINS WITHIN 30' DOWNGRADIENT OF GLENDON RESERVE AREA. 3.) The application was reviewed by the Jefferson County Department of Community Development staff on February 15, 2007 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: landslide hazard area 1; erosion. 4.) 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. 5.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 6.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 7.) Prior to and during approved construction activities, the perimeter of the landslide hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter Existing Vegetation." 8.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 9.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or any other prominent physical marking approved by the UDC Administrator. 10.) The applicant is proposing to create or add 2179 square feet of impervious surface and 6194 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. 11.) 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. 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 manufactured home installation application on January 30, 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 February 15, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. • M 14.) This approval is for a manufactured home installation 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 Leland Valley Road West right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. If an ESA is present, then the more stricter setback(s) shall apply. NOTE: Recorded Subdivision of Lords Lake Loop#2 identifies a 75 foot open space tract that runs parallel with Leland Valley Road West. A driveway may be located within the open space tract but no other structures or land distrubing activities are allowed. 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 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. 20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 21.) The building height is not to exceed 35 feet. 22.) A minimum of two (2) on-site parking spaces are required for the manufactured home. 23.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 24.) The site is served by an individual on-site well and was reviewed under USR06-0117 that was finaled on February 15, 2007. 25.) An address of 3402 Leland Valley Road West, Quilcene has been assigned to the parcel. Leland Valley Road West is a county local access (C343709). 26.) A road approach permit (RAP05-0207) was finaled on June 28, 2006. A septic permit (SEP06-0118) was approved on June 14, 2006. A well review (USR06-0117)was finaled on February 15, 2007. 27.) The lot was created through the Lords Lake Loop#2 Short Plat on September 13, 1996 under AFN 394609. 4V -.----- ."kC.. l. 4> MO N L -i 3 L,: /0. ,,,,,.,:.,,I fti•er f.......L....:4 I. . I a. 1 . , ...., "1"-• S., ., ,. ' 1 , .. .,... 'zit. ?.i ..'i 1. i_1...i ; t" .._........_. .... cf.,. 7,....‘1, ..Z.' • -.... .., . . . . ' ..., VIBE' 1 , i " (-C. . (01 i / ...x: ,,.. .,,_. • 3 ---....." . . • k_ t iF,-- . • . 6 kik . ,... : C..), \MI W 1 itAF i I I 10 reiA ,.. • OKI . • 0 0 a" • ...1. ..."... ‘k,,,ti,,, ,_ Sk.:....7 th V.-. k....1.... 1 • `3.7. 1... IN..' k r .. ...- x;- 0 i.--- ---z-c. :t - k.C.I..E L_-_.) „..---c- .. __. _..... ' '.!5..a . i ... C.k. ....„ki JACK WVESTERMAN I. Jefferson(o iitr Courthouse ASSESSOR I'O Box 1220, Port Townsend,WA 98360 (360) 31)5-9105 Tl�q l MOBILE HOME INFORMATION FORM ' 'A OWNER'S NAME/MAILING ADDRESS: ,_ JAN 3 0 2007 NAME:( ~C �� ADDRES : '7L Q,2 p Ah q ) `:i� O $ PHONE NO. �l ' —'7 ,' The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. 1)MOBILE HOME DATA: (A) MAKE (B) MODEL s�� G J L! 1J• C)YEARAUO7 (D) LENGTH (E) WIDTH c:7:?g/ (F)SERIAL # D` j . — (G) YOUR PURCHASE PRICE (Do not include sales tax) PURCHASE DATE 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 30 (A) FROM WHOM DID YOU PURCHASE MOBILE Pei- :0-0ot_ 03 /((:).,/} ADDRESS 'Y tea— /07 (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No) If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. /1/4 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME it ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE-MHO E PARK: NAME OF LAND OWNER: C-� "'� LOCATION ADDRESS REAL PROPERTY PARCEL #/DESCRIPTION /.Oof UoUv6 Si nature of applicant THANK YOU FOR YOUR HELP! ' QQ JO I i COSSELL, Property Technician • PERMIT .Q$Oz� c� Q - j -t _ JEFFERSON COUNTY DEPARTMENTJAA f1 OF COMMUNITY DEVELOPMEN T 621 Sheridan Street • Port Townsend • Washington 98368 flow, O 360/379-4450 .360/379-4451 Fax irmo i ' -_ ' http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# Dl—3(1 PROJECT/APPLICANT NAME: /efe-?-kk^'..fa^.,.-��� cl •! . 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 ev e '7 2oA 1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the site map. tau.", a / /. t . ) s a ,��. gwtc. 0 ,fie; / X 7 ett 4,-ke at.-keet..` .. Existing Conditions Summary 2. Des e,the existing topograp Indicate conttours �he si,q map, *. ..d.. • /• e /2J � i = d s�f/y/A�'J /�{y{�+•y r 3. Describe the existing vegetati p. Indicat native veget-tion areas on ie site map 011100- ,L tj A, �• •_ ►. / J r i . ..�. .:.'"tr 2 .il!'v 0 y 4. Describe the wisting soils. Indicate soil type on the site map. ot)ic 4.to ct.)44 i r Loa 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. �.� '_ ` �t •'c ' __1 /1 O 46)' -?'t e G1.G_c 6. Describe any excess levels of noise general by the proposed use or activity APPROVED STORMWATFR PLAN Stormwate lr`,� , Required ,11✓•, FEB 1 5 2007 stormwater site plan template—rev.10/1/2003 , 5 IEC RS J NT DEPT.OF CM Y • L .N ctC!.'Art IQF / • • 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.). ,L G0-1 buoy,&lee_kr) ag5 0 gt'a�( d,tf2 .e. a 1m 5o ' t �/1�tec( /tom 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. Gam... 7'` a > 0 —A Ae-�-C C�. 1. � 1.101121. ` _ 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. If- er/b "Ze-10: Describe a t4low control system. 12 y s fi 1 F A L...t. ; `ftormwater site plan template-rev.1011/2001—"` 6 1t r t '� — --, i 13. Describe the water quality system. J f1H 3 0 200? cg247- irb AIN ' � ti � 14. Describe the conveyance system analysis and design. _295 � 15. Describe the source of fill material,physical characteristics)of fill material,and deposition of excess material. 14- 41 a Kaxl....TT e — afe... , 16. roposed methods of placement and with action consistent P the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 4,0444/ I. 18. Describe methods for restoration of the site. "A-40-441 ./rd A,t_4.1h—dj Iftreal,1-1 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. ®l/Ce 20. List here and 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 requirements,describe those conditions or restrictions here. 4/62. stormwater site plan template—rev.10/12003 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 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. 2. Establish Construction Access. • 3. Control Flow Rates. 4. Install Sediment Controls. .74* ,7 .S _..-1! 11 f;( 5. Stabilize Soils. r.1117'd--111, ../1/20010re :".#14r1 14,15kIndk4 6. Protect Slopes. 7. Protect Drain Inlets. stormwater site plan template-rev.10/1/2003 8 • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 3 O 2N? c ` � 4�ci t 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. £ G� 2. Adj A . a. acent 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). ,i(-2741,/ 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. i stormwater site plan template—rev.10/1/2003 9 • • , b. Description of special requirements for working in or near environmentally sensitive areas. /t 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). /7 Cv 5. Construction Phasing. a. Construction sequence • 4 2A0,9. —uvLatiiair, ff`Z.,tu rat `` ' $ '. .t _,Lt .: cejec f b. Construction phaslfi'g(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. II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. i/r/741 , 7. Financial/Ownership Responsibilities. -a. �1entity the property o per res onsible for the init of bond and/or other financial securities. ,fit 9C- ,t�"/ ��;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. a(l , b. Diversions. r` c. Waterways. f d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.10/1/2003 10 • • 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 my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of th t;ffeecctteed property. ,.d I -Q( -07 '(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: stormwater site plan template—rev.10/1/2003 12 44 o l C'0 JEFFERSO•OUNTY • ,`day DEPARTMENT OF COMMUNITY DEVELOPMENT I'w y 4 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax 41S 7 40' www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: C' I ' Project Description(include separate sheets as necessary): Tax Parcel Property Number: 96)20 �Q 2 9 Size: a t o �1,.� (/.-k- (acres/square feet) Site Address and/or Directions to Property: .jO V (1- ' 1 s 1. ,, , Property Owner(s)of Record." ta. ,a' Telephone: ') '' - © Fax: "' r .._:t 9 email: d� �:��°al.vt � . Mailing Address: q 4 __.3,.c:..,at.,. ,*. es-d i / -e.Y.z.4 ' ...tz P. Applicant/Agent(if different from owner):� Telephone: Fax: email: Mailing Address: 'Vhat kind of Permit?(Check each box that applies) Building i Variance(Minor,Major or Reasonable Economic Use) i Demolition Permit I Conditional Use[C(a),C(d), or C]** 1 Single Family i Discretionary"D"or Unnamed Use Classification i Garage Attached/Detached i Special Use(Essential Public Facilities)** VI Manufactured Home i Boundary Line Adjustment i Modular I Short Plat** i Commercial* I Binding Site Plan** i Change of Use i Long Plat** I Address i Road Approach i Planned Rural Residential Development(PRRD)/Amendments** i Propane I Plat Vacation/Alteration** I Allowed"Yes"Use Consistency Analysis i Shoreline Master Program Exemption/Permit Revisions** Stormwater Management i 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 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). OWNER SIGNATURE 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,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 right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. 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 wants prior notice. // rl Signature: • /�l/�� (s ��'¢'� ��' L�. ,// Date: Pt "r/ C'/ The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable responsibility for adhering to and complying wi -the ESA. The/-A ant has read this disclaimer and signs and dates it below. Signature: - - �� �-f� f �� Date: —O�y�() /y G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Xjnature: Date: `�` / ` -� 4— ��J`.` !� r` /4 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: eii New a Wood Existing: Sewer ❑ Addition Li Steel Proposed: Bank U Community System ❑ Alteration/Remodel Li Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# r',3 ,—Cry/2 ❑ Demolition ❑ Other: Bedrooms: Water Supply: � ( Existing: A Setback: X Private well LI Two Party T e of eats r Proposed: C] Public � �+i �Z E Total: r u� Name of System: 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. 'NW 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 / ✓ EH Bld App Review: ; 2"6 Floor Heated Consistency Review: �( \j/��}) 1R_ JlJ Other Heated Base fee: l �OO Mezzanine Additional Section: �j Heated Basement Plan Check fee: Unheated Basement 4!4' ',: State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport /74 SUBTOTAL 171 cr0 Decks 911/Rd Approach fee: eYJ STD -_____ Other TOTAL: $ Receipt Number: IJ'r ,q Cash/Check Number: _ ESTIMATED COST(REQUIRED) Date: _ 'Fair market value of all labor and materials foundation to finish _ 1 Initials: G:\PermitCentcr\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc RETURN ADDRESS Pacific Coast Escrow 350 w. Washington st. , Ste. 3 Sequim, WA 98382 • Manufactured Home t:]11 �9a[d:lXd.'('1'f�i ,,J WASHINGTON STATE DEPARTMENT OF TITLE ELIMINATION �.L• LICENSING Application ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,imprisonment,or both.(RCW 46.12.210) 0 MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH F ET) VEHICLE IDE TIFICATION NUMBER(VIN) 2007 Skyline 52 x �q - 0 ccL ; k.0 {Nf'� © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE ,AFFIXED 0 REMOVED 702 024 029 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 2 Lords Lake Loop#2 Short Subdivision © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Larry G.Ross NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Katherine J. Ross ADDRESS CITY STATE ZIP CODE 742 Peterson Road Port Townsend WA 98368 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER National City Mortgage,a division of National City Bank NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 15 Oregon Ave, Ste 200 Tacoma WA 98376 GRANTEE NAME The Public I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE t -5.,•,vv7.�k- A 6 r <! l Signature of Additional Registered Owner and Title,IF APPLICABLE e(:� 1�t-e-Gc �-C. .) NOTARY SEAL OR STAMP I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNE (S)SIGNATURE tate of Washington Signed or attested LESLIE ASIN County of C.-L&A OJY7 before me on L eO NOTARY PUBLIC I p� (� STATE OF WASHINGTON I�Y L9 W`� SignatureLe....,. C�- ."Y> PRINT NAM REGISTERED OWNER NOTARY OR AGENT COMMISSION EXPIRES MAY 9, 2009 I(y �o- 12 C it�C. �� - Rt7SS \_ES\tE'_ ti��trl '\,_., -,,,-�",,^t1'�-`^�,,1 •••,;v PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY Ae County/Office No.OR tV I Title t'A AND: Dealer No.OR 5'0 -0 9 I DEALERSHIP POSIT(�AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAM (TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER C 1 t C P_fl R�t st-N rtcCi.n I I-I I�' � � -I � SIGNATU /P TI N ATE Q 2_Qccrdlnc CJFncer Li-H-0Y Finaliz this application with a Licensing Agent within 10 calenda days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION I Certify that g the manufactured home has been affixed to the real property as described. a building permit has been issued for this purpose and the attachment will be inspected upon completion. 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