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HomeMy WebLinkAboutBLD2007-00060 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 #: BLD07-00060 SITE ADDRESS: 189 BENTLEY PL Issue Date: 03/27/2007 PORT TOWNSEND, 98368 Final Date: 9/7/2007 APPLICANT: MARIA C ARCEO PHONE: 360-732-0563 SALVADOR JIMINEZ 104 RHODY CT CHIMACUM WA 983258720 SUBDIVISION: LUNDSTROM'S ADDITION Block: 1 Lot: 1-12+ PARCEL NUMBER: 969600101 Section: 24 Township: 29 N Range: 02 W PROJECT DESCRIPTION: NSFR W/ATT GARAGE THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: R-3 TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 9/7/2007 rr , yboi 91747 Building Official Signature C Date I:\F_BLD_Occupancy.rpt 10/29/19 OIILDING PERMIT APPLICATION ML v 078 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00060 Received Date: 2/20/2007 SITE ADDRESS: BENTLEY PL PORT TOWNSEND, 98368 OWNER: MARIA C ARCEO PHONE: 360-732-0563 SALVADOR JIMINEZ 104 RHODY CT CHIMACUM WA 983258720 LUNDSTROM'S ADDITION SUBDIVISION: Block: 1 Lot: 1-12+ PARCEL NUMBER: 969600101 Section: 24 Township: 29 N Range: 02 W CONTRACTOR: HILINE HOMES PHONE: (360) 379-8600 94 KALA SQUARE PLACE PORT TOWNSEND WA 98368 Contractor's License HILINH*981BT Expires 2/10/2008 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI' NSFR W/ ATT GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,112 VALUATION 201,743.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: 528 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CMY WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,564.95 LYK 02/20/07 89423 APPROVED Plan Check $1,017.22 LYK 02/20/07 89423 State Building Code $4.50 LYK 02/20/07 89423 MARa�] 2007 Potable Water Application $58.00 LYK 02/20/07 39423 Total: $2,644.67 Jefferson County Planning & Building Department Jefferson County Building Dive -ion Permit Num• BLD07-00060 Applicant: ARCEO 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 / 4/ (67 ✓ Erosion Control 41/J/61 6 U Foundation Footing `t f� 4/74I /N57ALL60 Footing Drains 5 f)410 �l nK Foundation Stem Wall 4,I ( Under Floor Framing S/407 el( Straps(hold downs) Ext. Shear Wall Nailing 1/$07 s OK 7e-r a f Pe rw aK S/8/n7 ff Rough-in Plumbing C, 7 I 6‘.%.11�iZ Framing 7/4-07 r� Blocking Airseal Insulation:Walls 76 , 6-7 1913 Insulation: Floors 1/11/6/ 0 Insulation: Ceiling COO G// 124 Int. Shear Wall Nailing COO 1� Wallboard Nailing � �7 : .7 ‘? Gas Line: Interior f A Gas Line: Exterior N>A Propane Tank N /A Heat/Chimney Clearance 14/a Drywell/Alt Drainage 3I14 dJ1-14./4-CLILuE A20ulUF) 04/1u5 Address Posted q/4 a U FINAL INSPECTION FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR 4110 • CONDITIONS for Building Permit# :BLD07-00060 1.) The application was reviewed by the Jefferson County Department of Community Development staff on March 2, 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; coastal SIPZ. 2.) 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. 3.) 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. 4.) 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. 5.) 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. 6.) The applicant is proposing to create or add 4400 square feet of impervious surface and 7140 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 7.) A Stormwater Site Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 8.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i). 9.) The site plan as submitted with the building permit application on February 20, 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 2, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 10.) This approval is for a single famil sidence with attached garage only. Any fUL e permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 12.) Not more than 2 unlicensed 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. 13.) Minimum setback from Bentley Place right-of-way shall be 20 feet. Minimum north setback shall be 35 feet from the adjacent commercial zoned parcel. Minimum side and rear setbacks shall be 5 feet. If an ESA is present, then the more stricter setback(s) shall apply. 14.) 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. 15.) 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. 16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 17.) The building height is not to exceed 35 feet. 18.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 19.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 20.) An address of 189 Bentley Place, Port Townsend has been assigned to the parcel. Bentley Place is private (P613). 21.) The lots were created through the Lundstrom's Addition Subdivision on January 27, 1890; no AFN available. 22.) The parcel is served by the Moa-Tel public water system. 23.) A Declaration of Restrictive Covenant was recorded on February 14, 2007 under AFN 520438 to consolidate Lots 1-12 with adjacent vacated streets within Block 1 of Lundstrom's Addition. The purpose of the Covenant is to meet minimum land area requirements for on-site septic and allow zero lot line setbacks to common boundaries. 24.) The parcel was cleared around 2003. The Shoreline Slope Stability maps identify the portion of the parcel where the house is proposed in stable. The landslide hazard area maps identify the area where the house is proposed as slight. The parcel has a gradual slope from east to west. The mapping appears to be inconsistent with the topographic map which identifies the steeper slopes to the east; approximately 200 feet east of the proposed home site. . I , r �` \� , I } ON CC7 il'‘)- ;jle �Y 1�!t )' JEFFERSON COUNTY l ,: 1 DEPARTMENT OF COMMUNITY DEVELOPMENT , 621 Sheridan Street • Port Townsend • Washington 98368 �O 360/379-4450 . 360/379-4451 Fax NO http://www.co.jefferson.wa.us/commdevelopment/ EMPL � � STORMWATER SITE PLAN SUBMITTAL TATE MLA# Di-r-iz PROJECT/APPLICANT NAME: t Ct do t �J i\m of.e 2_ 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 1-site map. �, o (1On.c�ck ct „ Sq ,i N� �ih le_c-gm Lj Esrd ice_ n nl f��"X ih ��. P for i s pax 2 0 x�S 0 Existing Conditions Summary 2. scribe the existinq topography. Indic to contours on the site m p. 3. Describe_ he existing vegetation. Indicate native vegetation areas on the site map. s If / ! 4. cribe the existing soils. Indicate soil type on the sit map - l S 51:t11 ci , p' 2- 1 ,/ UIL�- e?Q °C l I Qife an oi 12 W' .PAn'(4 X �- 6) 4- IA he (1 f() e;... S I ni 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. f, Ai-Vire{ tS latte( P.V-en rl p ` -D od`f pY7)%ry ,---rt)y\ Aiac(w14- LA. ©in o -�o +ke- e y1--y e,h ft - na-A-_tenl 1 6. Del scribe any excess levels of noise generated by the proposed use or activity: APPROVED , yt I S 2 0'o_C prOu ciAvitl SThgi- AN tormw t MAR - 2 2007 Required cU stormwater site plan template—rev.10/1/2003 DEPT.0 C I V . 1 :ENT 5 SIGNATU E: iti 0 • i 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the ite. Indicate location on the to map. ,t ln,�f e,r (o p 3 :- e-D)-n eetS+ Le_ c- Lm- 're - 8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads, and sensitive/critical areas ( treams wgtlands,lakes,seep to es,etc.)., Itrifz.„ OltridpvN kviaortri-avv) , 614\ d r .e) p(-4-ra__ 4/(tx.... 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. 9. 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 hin he site. _ocate these fa ilities on the site plan and differ tiat propose facilities from xistin cilities. �'� r wit i l b-e- 1 j dill 22 , ;� i . 04,4? ra-A, .-5 A-axe_ w ail 5 Lop- 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 potenti I for dispe ion ofTntaminapts.] b n io `�`Le'z A ---jet - c�° lit e� . 11. •i scribe t p rfp�rmance goals and standards appfcf�ble to the project. 1 I / it±f k C J pAi T 1 I lk� fik, 1 h�7�v►�t c !' ,1 A . ' G 12. De c ibe the flow co trol s m. .,____ Oadt ji)4 ' "* KYVI/le< 2/011, S 11?/),,, YWI'Ai- 'AP,4e/ita P' / f t I1. ...,. ' iti tormJ,tdi side 0Ie6,3emplate-ted 10/1/20036 if?.T'' ', i 6 i is • 0 13. De be thew ter quality system. ` � ' euvLeklyk.9 Li), - 0 au 14. Describe t e conveyance system analysis and design. .,' � � ic(.4--\ 15. Desc ibe the sourpe of fill material,physical character'stics of fill material, d deposition of a ess material. g 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the UniformBuilding Code. e_.- (t.e)1,&vic 2/0C,LezA-a-(-- -, Li/" -1 lOvin �:CI 1,(4 (l �(�i 1�" of t S�l 1/Y �7 07 r 17. D ribe the proposed surfacing material. alre 9/)-ivi,s ---t6 u-si.--e- 9 mei. 18. Desc'be methods fof restoration of the s'e. �- [[ a�`rrrr ay /- ,reel, We- w�c I/ /ayndyw_e___,gLA c 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. iti t ii--- 20. List here and joclu�Je 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 restr tions here. 19417QIS,-1-t VYN a n 4 dri"A 040 stormwater site plan terrplate—rev.10/1/2003 7 9 • 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 Karl,/Clearing Limits. Establish onstruction Acces Ile.i/i 12 JjiS 11 A iV Ul aL-6.-&-,-4 3 Control Flow Rates.ri 4.-4 -4,4ra a, 4z) 1},04 ,-1-- ,f� rynie,c) .rJ 4. In all Sediment Control -id i7I v c' _5 (Op 5 15 nd 4 1// s(--s(a� y 5. Stabilize Soils. ra 5 la)1(1. crp q Pr t ct Slopes. . fP L n...+.._.t f /ll.oi-, Inlcte 41 stormwater site plan template—rev.10/1/2003 8 • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. IL 11 9. Cotrol Pollutants..06rK C,Ieji5 10. Cgntt ool De-Watering the apt of pu ping r n aier or stormwater away from an active construction site). par, ao,- - ' I) /la V Cy 1 Maintain Best Management Practices(BMPs). CA &il O 10 0.d) x72[4r1Y 1.t 4 t( Yeteicve_ j n S-:Yu rMrYA S. 12. Manage the Project. *vr. uff' 1 I oflY0- +- ^ � '�� L {,r lime` P�1�1YC'tvR'}gv,,1 �- 2. Adjacent Areas. a. Description of theacc�acent arif that may be affected by site disturbanc_e (e.g., streams, lakes, wetlands, residential areas, roads). b. Description of the downstr am drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). ill :_ A 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. 0 / , fi FED 2 stormwater site plan template—rev.10/1/2003 9 • b. Description of special requirements for working in or near environmentally sensitive areas. 1 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). it_ 5. Construction Phasing. �.Co ru tin peguence Q' I I�U < dryl.reir rn�vu�� t o �� i tsv. ?R_Jv am Cet 1,9 b. Construction phasing(if proposed)+r 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. t�) V b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the prop rty owner responsible for the'vitiation of bonds and/or o er financial securities. 14p(I 7 t iA!H©Y J?C) Q4 Yo he) b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation " impacts.ii2 ratpo+y 0ui>701' /ees 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. a. Sediment Ponds/Traps. 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 t affected pr perty. A.-6:7Z- (LANDOW IZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: stormwater site plan template—rev.10/1/2003 12 ,44;5, j, JEFFERS 0UNTV • I .E. ' `'.E t, 0 It /r • r `‘� ` r} DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax FEB 2 0, 2007' ,gS,IN0,0 www.co.jefferson.wa.us/commdevelopment Master Permit Application MLAJ[f f f!m; I I' 4; dILJ Project Description(include sepa ate sheets as necessary): Tax Parcel n 1 ( () I Property'-�C . j (acres/square ) Number: Size: , J acres/s uare feet Site Address and/or Directions to Pro erty: Ben+k � . PO f- Tuipx i WP- I Property Owner(s)of Record: 3 "n Telephone: ` ��� OS 3 Fax: " S C 3 email: Mailing Address: I t "rpd t/Iiy ct'3 ZS Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit? (Check each box that applies Building 0 Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit 0 Conditional Use[C(a),C(d),or C]** mingle Family E Garage A_ttached-/Detached 0 Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)** ❑ Commercial* ❑ Boundary Line Adjustment ❑ Change of Use ❑ Short Plat** ❑ Address 0 Road Approach 0 Binding Site Plan** ❑ Home Business 0 Cottagelndustry 0 Long Plat** ❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑ Sign 0 Plat Vacation/Alteration** 0 Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request *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 applicati n tha 'e9sh wants_ prior notice. Signature=-. - Date: 64 - 14- 04 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 com Nance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfera 1 re gd si6ir fo dhering to and complying with the ESA. The Applicant has read this discidisqaimer and� signs/and dates it below. Signatur . Date: 1 ki'e- / 62...-6 G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.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. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: Fax: #� unQ - 1Yke_2:. 060)33q- 60e (32o) 3t--4 I 11 MAILING ADDRESS: 14_ Latta,S/1,ace *p f MAIL: CONTRACTORS LICENSE I "� WAINS NUMBER: J , Li NA)* qg 1 ET NUMBER ARCHITECT/ENGINEER: Li' PLO_ `C l PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL reepeng i A ee.rl"nq Aa.ri-er.n e - Prolect Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: L 'New W Wood Existing: ❑ Sewer ❑ Addition ❑ Steel • Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: $$: Public ''��)),,II�, Total: Name of System:00 fa Wald' If this is a Commercial Protect 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: 1 Underground Tank 1 Above ground Tank Size of Propane Tank: 1 Heat Stove i Cook Stove i Woodstove 1 Fireplace Insert i Hot Water Tank i Pellet Stove 1 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 I t -) IVZ97% EH Bld App Review: (cgda l L- 2"tl Floor Heated Consistency Review: 155 c° Other Heated Base fee: I D,`( (15 Mezzanine Additional Section: � , Heated Basement Plan Check fee: ►oirl .aa Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: q (' Garage/Carport fV5-hltile2.2 ''ayt.H q(P SUBTOTAL �� aqo0 . 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