HomeMy WebLinkAboutBLD2007-00030 CERTIFICATE O.F 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 #: BLD07-00030
SITE ADDRESS: 52 TERRACE LN Issue Date: 03/1/2007
BRINNON, 98320 Final Date: 4/10/2008
APPLICANT: LEE WEEKS TRUSTEE PHONE: (360) 796-0313
PATTI WEEKS TRUSTEE
50 TERRACE LN
BRINNON WA 983209631
SUBDIVISION: SEAMOUNT ESTATES DIV 3 Block: Lot:
PARCEL NUMBER: 993400021 Section: 31 Township: 25 N Range: 02 W
PROJECT DESCRIPTION: NSFR W/ A/G 500 GAL PROP TANK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003
EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes Crio)
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 4/10/2008
I:\F_BLD_Occupancy.rpt 10/29/19
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UILDING PERMIT APPLICAtN ML vT
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00030 Received Date: 2/1/2007
SITE ADDRESS: TERRACE LN
BRINNON, 98320
OWNER: LEE WEEKS TRUSTEE PHONE: 928-854-4456
PATTI WEEKS TRUSTEE
50 TERRACE LN
BRINNON WA 983209631 SEAMOUNT ESTATES DIV 3
SUBDIVISION: Block: Lot: 21
PARCEL NUMBER: 993400021 Section: 31 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: MARK GETZENDANNER PHONE: 360-379-8125
5825 OLD GARDINER RD
PORT TOWNSEND WA 98368
PROJECT DESCRIPTIOP NSFR W/A/G 500 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,728
VALUATION 360,296.00 ADD'L: 385 HEAT TYPE: RAD
CODE EDITION: 2003 HEAT BASE: 1,728 HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: 680 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 3
Total: 2 Total: 3
Routing Date:
--)
-
Type ount Paid By: Date: Receipt: Approved/Date
Permit $2,455.35 LYK 02/01/07 84902 APPROVED
Plan Check $1,595.98 LYK 02/01/07 84902
State Building Code $4.50 LYK 02/01/07 84902 MAR \ 2007
Potable Water Application $58.00 LYK 02/01/07 84902
Jefferson County Planning
Total: $4,113.83 &Building Department
Jefferson County Building Dition Permit Num-: BLD07-00030
Applicant: WEEKS TRUSTEE
BUILDING PERMIT INSPECTION APPROVALS \pplicable Code: 2003 International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:0C)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
l
Setbacks
DEC 4/3/4,7 J b C 1)1 (�It\)
Erosion Control
% 4
Foundation Footing
Olt 3 e7 St7 'C ! �
/ I V\
Footing Drains r
6.30-61 Y0*.- Sea. IXr�s � ,
Foundation Stem Wall 4/13/aleti oK
FE :s G � bN► it (
(u 4/I LG /l -b -(c"tii"7Underground Plumbing ILI )-2 ' `1A'� I4
Straps(hold downs) r 1 r
Ext. Shear Wall Nailing 36 6D mheor � —
Rough in Plumbing 71 171e,I
)-f-------
Framing nn
APPRA Lsb BY W7-P A/23/07
Blocking
`---:
Airseal Z').0 APSat A 9/7/o7 4/
Insulation: Walls _ )�• _ t
Insulation: Floors ` (
"� 2.1/ei/ L?---- 51-t(3
Insulation: Ceiling Ihoill by x
Int. Shear Wall Nailing
00
a7 .6Y TG
Wallboard Nailing t7, 1 i,I b, i /
Gas Line: Interior .if/ l?//'2
U --'
Gas Line: Exterior I ' -iv-1 9t-
Propane Tank -. '`' "C)7 '
Heat/Chimney Clearance
Drywell/Alt Drainage C
5-36- 1 w 6P- SG&_ VigA
Address Posted
Fo If,I Le cl both COYre C t 16- -k--s On Corm C. -f 1,o\--\
FINAL INSPECTION '3)31 101E C cif' 3:114 , '( %ce , /1Q/0 F aro
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD07-00030
1.) HOLD-PRIOR TO OCCUPANCY, FINAL APPROVAL OF SEPTIC SEP05-402 IS
REQUIRED.
2. ..fiN11 REQUIRES NOTICE TO TITLE FOR BEDROOMS. SEP05-402 FOR 240GPD MAX.
\ b) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM
SEPTIC TANK, RESERVE & DRAINFIELD.
c)ALL COMPONENTS OF THE SEPTIC SYSTEM ARE TO BE COMPLETELY
PROTECTED FROM VEHICULAR TRAFFIC OR MECHANICAL DISTURBANCE.
3.) The application was reviewed by the Jefferson County Department of Community
Development staff on February 16, 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:
eagle/spotted owl; landslide 1; SUSC aquifer recharge area; coastal SIPZ.
4.) 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.
5.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
6.) 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.
7.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
8.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
9.) 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.
10.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
11.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
12.) The applicant is proposing to crear add 2092 square feet of impervious sure and
2200 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.
13.) 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.
14.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
15.) 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).
16.) The site plan as submitted with the building permit application on February 12, 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 March 1, 2007 shall be resubmitted for
review and approval by Jefferson County Department of Community Development.
17.) This approval is for a single family residence with 500 gallon above-ground propane tank
only. Any future permits on this site are subject to review for consistency with applicable
codes and ordinances and does not preclude review and conditions which may be placed
on future permits.
18.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
19.) 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.
20.) Minimum setback from Seamount Drive and Terrance Lane rights-of-ways shall be 20
feet. Minimum side yard setbacks shall be 5 feet.
21.) 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.
22.) 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.
23.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
24.) The building height is not to exceed 35 feet.
25.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
26.) An address of_Terrace Lane, Brinnon has been assigned to the parcel. Terrace Lane
is a county local access (C206809).
27.) The lot was created through the Snount Estates Division 3 Subdivision on J•4,
1974 under AFN 224234.
28.) The parcel is serviced by the Seamount Estates Community Water system.
29.) A septic permit(SEP05-0402) was approved on February 17, 2006.
30.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
31.) The county GIS mapping appears to be incorrect in relation to the landslide hazard area.
The parcel has a gently slope to the south. The steep slopes are located approximately
170 feet to the northwest and about 150 feet to the south. The parcel has approximately a
12 foot drop in elevation from the north boundary to the south boundary over a distance
of about 150 feet.
32.) Per phone message on February 27, 2007 from Shelly Ament, WDFW biologist, the
parcel is greater than 800 feet from a nest and not shoreline property. Therefore, there is
no conflict with eagles or their habitat.
•
' 8 , JEFFERSON COUNTY ki DEPARTMENT OF COMMUNITY DEVELOPMENT r
621 Sheridan Street • Port Townsend • Washington 98368
IC'(v4 360/379-4450 . 360/379-4451 Fax
http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# O { - PROJECT/APPLICANT NAME: Le e_ - PCL+1-1 we elks re_S AC-42-
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. (� n , /t
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.(n
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+�eQS J ShrGans 1 e;- raSS
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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5. Describe the existing site hydrology(i.e.,drainage;behavior of water on the site—above, below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of each.
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APPROVED
6. Describe any excess levels of noise generated by the proposed use or activity: STORM W ATER PLAN
N�he_
Stormv� t• '' 0, MAR - 1 2007
Require441 '
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DEPT.OF 0, • L PME
stormwater site plan template—rev.10/1/2003 SIGNATURE: 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.
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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 ' , rI
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation.of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
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11. Describel1 the performance goals and standards applicable to the project.
kV
lam?-Describe the flew control system:---
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13. Describe the water quality system..
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14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,p ysical characteristics of fill material,and deposition of excess material.
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform I:Building Code. t -�
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17. Describe the proposed surfacing material.
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18. Describe methods for restoration of the site.
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
"large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here.
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20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
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21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here. Add
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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
will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits. / �,,
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2. Establish Construction Access.
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3. Control Flow Rates.
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4. Install Sediment Controls.
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5. Stabilize Soils. /�
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6. Protect Slopes.
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7. Protect Drain Inlets.
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storrnwater site plan template-rev.10/1/2003 8
• •
12 Required Elements-Construction SWPPP(continued)
8. Stabilize Channels and Outlets. ;
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9. Control Pollutants.
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10. �ontrolDe/Watering(the act th pumping groundwater or stormwater away from an ac ive cons ruction site).
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11. Maintain Best Man Bement Practices(BMPs).
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12. Manage the P oject.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads . /n� ff ,,�} n
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
/UO iot 42
stormwater site plan template—rev.10/1/2003 9
• .
b. De cription of special requirements for working in or near environmentally sensitive areas.
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 struc`re).
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5. Construction Phasing.
a. Construction sequence
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Prpvide a proposed construction schedule.
Ntr4( \ — Sep-1- .
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
M n I eX-Cava.r4-IbPi d- CON.cvV -Co t.t dildeefh3 44
b. Proposed wet season construction activities for environmentally sensitive areas.
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
Cee .i eat-4- We e -5
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. 1(_.q
b. Diversions.
c. Waterways.
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 the affected roperty.
(LANDOWNER OR AUTHORIZED R ESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
stormwater site plan template—rev.10/1/2003 12
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Int)
JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENTFEB 0 1 2�J07
621 Sheridan Street• Port Townsend • Washington 98368
4.
360/379-4450• 360/379-4451 Fax
q 0 www.co.jefferson.wa.us/commdevelopment
. tfflitillt filINP tICI
Master Permit Application MLA: 0i7- 59
Project Description(include separate sheets as necessary):
A/P Lc) Cnn5-Jrk C'lch_ S i`vta/�P -caw., . I y vp� i`ciP1c `P
Tax Parcel J / Property
Number: 9 9 3 if b 0 O / Size: (acres/square feet)
Site Address and/or Directions to Property: 7P r ray,e Lct vt p / Bt,•hrt d r1, 1_0A 983. (-,
Property Owner(s)of Record: Le p ,4- Pa-/--I-1 /A)A p KS
Telephone: • 2$- : - 1 Fax:n � email: leek�ee-1-9-,@a r/'a2,4e'�"
Mailing Address: 15-3 y g eac1A CON4 •• Ir b 1 VdC Lc ice 14a.Va 51.( C,•l-t.f A Z S 414/03
Applicant/AgentJJ I
(if different from owner): M a✓'K G e.-F a ev.da r.A Q r
Telephone: 3 go -379- '1 2 S Fax: email: p 4,CO Ai
Mailing Address: rt }'2 t' O(bQ Gc,ri t r✓t r c'f.."lbw P �4 J 9 6
What kind of Permit?(Check each box that applies)
li$uilding ❑Variance(Minor,Major or Reasonable Economic Use)
Ii Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
Single Family ❑Discretionary"D"or Unnamed Use Classification
Garage Attached/Detached ❑Special Use(Essential Public Facilities)**
❑Manufactured Home El Boundary Line Adjustment
d Modular UShort Plat**
❑Commercial* °Binding Site Plan**
O Change of Use ❑Long Plat**
Q Address 1 Road Approach . [Planned Rural Residential Development(PRRD)/Amendments**
Propane 10Plat Vacation/Alteration**
DAllowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions**
OStormwater Management ❑Shoreline Management Substantial Development**
OSite Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Variance
DTemporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
DWireless Telecommunication* OJefferson County Shoreline Master Program Amendment
❑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 N/401 r bre)Zi JQ,-Jc) to act as my agent in matters relating to this application for permit(s).
f
OWNER SIGNATURE p _ 4. .eje , . Date: Al— J3t_ ,!:)44
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
1
�, \ time of the appli that he or sM wants r notice.
Signature: �lyQQL
fff PpDate: /�=/r,!_�,�
v
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-transfer responsibili r ad ng to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Per. �� �/ Date: ��'— _ f�a
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D:\PermaC;enter\t O RMS\D M FORMS\Master Permit Application 12-30-05-2.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 assumin the resspo"ility o General Contractor for the proposed project.
XSignature: �--, v 4/- Date: i'7--i Z OZ
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:
• New Z Wood Existing: N/,ld 0 Sewer
❑ Addition ❑ Steel Proposed: 3 Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: -i Height: gIndividual System
❑ Repair 0 Masonry SEP Permit#SEP O S-ao yDR
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well 0 Two Party
Type Qf Heat: Proposed: —2` 12 Public
f,ad Itovr-k- -no or Total: 2 Name of System: Sect NAoKWt
EF P ❑ 4 4e5 Wr!`4erN—( cgefry
If this i a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current - Proposed _.
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
In Underground Tank XrAbove ground Tank Size of Propane Tank: S.0 0
Heat Stove Wook Stove 0 Woodstove ❑Fireplace Insert hir Hot Water Tank 0 Pellet Stove p 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 t)s 'Ly , ,,',., .1,ems. ..,, ...:, *eit- 0 ...,:
Main Floor Heated t 7.ZS 1 Q 04 EH Bld App Review:
tr3ap
2n0 Floor Heated Consistency Review 755.7°
Other Heated msialcootBase fee:
Mezzanine Additional Section:
Heated Basement ' 7.2 g 15i $b� Plan Check fee: 9�
Unheated Basement State Surcharge fee: O
A .50
Other Unheated L G ct �� 3t.5D1 Pot Water Review fee:
Garage/Carport SUBTOTAL `�� p 2
Decks b ,O I jZ'7(o0" /Rddproach fee: t
Other TOTAL: $,451
Receipt Number: 21(1400. '
Cash/Check Number: 13
ESTIMATED COST(REQUIRED) iCiLo `t Date:.Fair market value of all labor and materials four 'On to finish, all
br , _
'— Initials:
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