HomeMy WebLinkAboutBLD2007-00096 • II-
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
Al Scalf, Building Official
PERMIT #: BLD07-00096
SITE ADDRESS: 281 MUMBY RD Issue Date: 04/18/2007
NORDLAND, 98358 Final Date: 6/13/2011
APPLICANT: EDWARD W BREMER JR PHONE: 206-329-7591
JANE M GILSON
3307 E PIKE ST
SEATTLE WA 98122-3359
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 021202003 Section: 20 Township: 30 N Range: 01 E
PROJECT DESCRIPTION: NSFR WI ATT GARAGE & U/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 c
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 6/13/2011
I:\F_BLD_Occu pancy.rpt 10/29/19
itILDING PERMIT APPLICATION MLA07-00118
Review Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00096 Received Date: 3/12/2007
SITE ADDRESS: 281 MUMBY RD
NORDLAND, 98358
OWNER: EDWARD W BREMER JR PHONE: 206-329-7591
JANE M GILSON
3307 E PIKE ST
SEATTLE WA 981223359
SUBDIVISION: Block: Lot: 1
PARCEL NUMBER: 021202003 Section: 20 Township: 30 N Range: 01 E
CONTRACTOR: TIM MCGRAW CONSTRUCTION PHONE: 360-698-0191
PO BOX 688
SILVERDALE WA 98383
Contractor's License TIM MCC*122ML Expires 6/20/2008
REPRESENTATIVE: TIM MCGRAW PHONE: 360-698-0191
PO BOX 688
SILVERDALE WA 98383
PROJECT DESCRIPTION NSFR W/ATT GARAGE & U/G 500 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 897
VALUATION 175,000.00 ADD'L: 1,378 HEAT TYPE: PRO
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 1,001 SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 1 Prop: 1
Total: 1 Total:�� ( �
Routing Date: vT- 'N \7Ur^
13Ur1 CZ
Type Amount Paid By: Date: Receipt: APPDctD
Permit $1,413.75 LYK 03/12/07 89570
Plan Check $918.94 LYK 03/12/07 89570 APR t g 2007
State Building Code $4.50 LYK 03/12/07 89570
Potable Water Application $58.00 LYK 03/12/07 89570 Jefferson County Planning
Total: $2,395.19 &Building Department
Jefferson County Building E sion Permit Nu,: BLD07-00096
Applicant: BREMER JR
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2003 International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
Setbacks
3 1,8/0 7 tr' Is 5rAizira, Ay ow#0e--e_
Erosion Control
Foundation Footing ,)dTE r k&p 57v-a- SulTogma. Uf-G$m_
UFFE2. OK 511/d7 ,Footing Drains
Foundation Stem Wall
tt
Underground Plumbing
Under Floor Framing
Straps(hold downs) v2AVeirr "1 .o4-
Ext. Shear Wall Nailing
0i15, al li D —
Rough-in Plumbing
Framing
2 t'' ' ifi . 04_ APPfavan
Blocking 7 22!6� _ Ok_
Airseal _ /2 Q//61 O4_
Insulation:Walls 0.2fri
,#/ ny _ el.
Insulation: Floors
Insulation: Ceiling
thitfcr&D Zew-ar‘s 27/24.48frOiK.
Int. Shear Wall Nailing
4/7-#08 V 015B
Wallboard Nailing
3//0102) o4
Gas Line: Interior „
I i
Gas Line: Exterior ? '' --
6614 'FP
Propane Tank •_
Iwo V►410r
uNDEe-eouNu
Heat/Chimney Clearance
Drywell/Alt Drainage
Address Posted
FINAL INSPECTION �,,._O r-a 4p
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD07-00096
1.) NO INSPECTION FOR OCCUPANCY BEFORE FINAL OF SEP05-340.
2.) DIVERT ALL DRAINAGE AWAY FROM DRAINFIELD AND RESERVE AREA.
3.) The application was reviewed by the Jefferson County Department of Community
Development staff on April 17, 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:
Conservancy Shoreline Jurisdiction, Seismic Hazard Area along the bluff, Level III
Landslide hazard Area along the shoreline bluff, Special Aquifer Recharge Area,
Susceptible Aquifer Recharge Areas, High Risk and Coastal Seawater Intrusion Protection
Zones (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.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within Susceptible
Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit (4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
7.) 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.
8.) Buffers are areas that shall be maintained in their natural condition, however, minor
pruning or alteration of vegetation may be permitted as long as the function and character
of the buffer are not diminished.
9.) Among the native conifer species which may be used in buffers or for re-vegetation
include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis),
Shore Pine (Pinus Contorta), Douglas Fir (Pseudotsuga Menziesii), Western Red Cedar
(Thuja Plicata), and Western Hemlock (Tsuga Heterophylla).
Among native tree species which may be used includes: Vine Maple (Acer Circinatum),
Big-Leaf Maple (Acer Macrophyllum), Red Alder (Alnus Rubra), Pacific Madrone (Arbutus
Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa),
Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara
(Rhamnus Purshiana), Pacific Willow (Saliz Lasiandra), and Scouler's Willow (Saliz
Scouleriana).
Among the native shrub species which may be used are: Sevice-Berry (Amalanchier
Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean
Spray (Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark
(Physocarpus Capitus), Red Flowering Currant (Ribes Sanguineum), Wild Rose (Rosa
Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry
(Sam bucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry
(Vaccinium Ovatum), Red Huckleberry (Vaccinium Parvifolium).
10.) Marine shorelines and islands a•sceptible to a condition that is known as"water
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.
11.) 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.
12.) The parcel is located within a High Risk SIPZ (seawater intrusion protection zone)
according to the County GIS map. There are 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 High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses above 200 milligrams per liter(mg/L).
13.) 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.
14.) 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. •
15.) 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."
16.) All construction activities shall not encroach upon the buffer. This includes the storage or
preparation of materials.
17.) 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.
18.) 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.
19.) 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.
20.) VOLUNTARY MEASURES OF CTAL &AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
21.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
22.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
23.) MANDATORY MEASURES OF HIGH RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
24.) MANDATORY MEASURES FOiIGH RISK SIPZ: •
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-106
for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e) of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
25.) The applicant is proposing to create or add 3022 square feet of impervious surface and
3498 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.
26.) A Stormwater Site Plan for medium project 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.
27.) 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).
28.) The revised site plan as submitted on March 15, 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 April 18, 2007 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
29.) This approval is for a single family residence with attached garage 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.
30.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
31.) 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.
32.) Minimum setback from Mumby Rd right-of-way is 20 feet. Minimum side yard setbacks
are 5 ft. Minimum setback from the top of the shoreline bank is 67 ft.
33.) 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.
34.) Exterior lighting for residential ushall not exceed twenty feet(20') in heightTiSm the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
35.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
36.) The building height is not to exceed 35 feet.
37.) The site is accessed via Mumby Rd, a county local access road identified as C596609.
A road approach was reviewed under RAP05-00267 and an address of 281 Mumby Rd
has been assigned to the parcel.
38.) This parcel is a legal nonconforming parcel designated as Rural Residential 1:5 under the
Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998.
39.) A minimum of two (2) on-site parking spaces are required for a single-family residence.
40.) A septic permit (SEP05-00340)was approved on November 23, 2005 for a system of 360
gallons per day
0
• 0 APPROVED
STORMWATER PLAN
c°
d , JEFFERSON COUNTY APR 18 2007
-, kilo,Q DEPARTMENT OF COMMUNITY DEVELOPMENT _
621 Sheridan Street • Port Townsend • Washington 98363 JEFFERSON COUNTY
360/379-4450 . 360/379-4451 Fax DEPT.OF COMMUNITY DF PKIE7N0 http://www.co.Jefferson.wa.us/comrrldevelopment/ SIGNATURE.
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# Q'7 I PROJECT/APPLICANT NAME: ig � �„�~ 6/1,,4_n, 40 A 4.yj
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.
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Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
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SITE PLAN
3. Describe the existing vegetation. Indicate native vegetation areas on the site mao.
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4. Describe the existingsoils. Indicate soil rEFFERsoN CO
type on the site map. DE. .OF COMMUNITY DEv OPMENT
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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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6. Describe any excess levels of noise generated by the proposed use or activity:
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7.I Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
Isteep 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.).
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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 existingfacilities.
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10. If the project requires the use of stc rmwater treatment facilities, describe the types of stormwater treatment facilities proposed
for us$;cm thejsit4'p jocate 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. Describe the performance goals and standards applicable to the project.
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12. Describe the flow control system.
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stormwater site plan template—rev.10/1/2003 6
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13. Describe the water quality system.
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
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16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
17. Describe the proposed surfacing material.
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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.
20. List here and include any special reports or studies conducted to prepare the Stonnwater 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.
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stormwater site plan template—rev.10/1/2003 7
• • c
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.
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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.
7. Protect Drain Inlets.
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stormwater site plan template-rev.10/1/2003 8
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12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
9. Control Pollutants. A/A
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10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
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11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
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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).
A-O n—P
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmes tally sensitive areas that are on or adjacent to the site.
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stonn..ater site plan template—rev.10J12003 9
• •
b. Description 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 structure).
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5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.n
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps. /1I4
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 ffected property.
l0 , - 7` 0 7
( NE R AUTHORIZED REPRESENT IVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
stormwater site plan template—rev.10/1/2003 12
/SON e
/mot 0�,, JEFFERSOOOUNTY II
frk' 1 1 A DEPARTMENT OF COMMUNITY DEVELOPMENT
~' '"4 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
it O www.co.jefferson.wa.us/commdeveloprnent
Master Permit Application MLA: Oj - t l
Prniect Description(include separate sheets as necessary):
1..v S iiZ iv 4 ��T-K 6 , /t-%l,e (,v.L LJ/G-- ro: 64 c
Tax Parcel Number: / Zv v 0 , Property / -
b 2/ Size: ,) x.- n` (acres/square feet)
Site Address and/or Directions to Property: Z�/ /-1 v pi < 7 it.cl A,c,K r) (n,-r,j &,•,
Property Owner(s)of Record: Tei 64.-t-,rft-
Telephone: 20 e -- 3 z`>— -7 5-9 i Fax: email:
Mailing Address: 1 3 o 7 fi, irc s i S, 77/t L./.r 9 J-/2 Z-
Applicant/Agent(if different from owner): Ti n ri c 6,44 -
Telephone: 7e0 6"yb' c.iC/ / Fax: JGc 6'cik SCS 76
email: TC n M(J/L.9 tc;<-
Mailing Address:If)t; igu r X kr .S Iv r,p e4.•k i Si T bra Gv4 ve c 4 S/e.c c,.,
What kind of Pefmit?(Check each box that applies)
-Building ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]*"
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
ILGarage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑ Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
LI Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ 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
*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:
��� f DESIGNATION' OF AGENT
I hereby desig atrf �-6 -:"7- to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE ' - —
.n. Y /w/-` Date: T (:"
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 inspecti .Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
i
Signatu(e:
, 4 �' cam/',
Date: =0 /
The action or actions Appl' aatwill 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-
transferab)e responsibility for a, . g to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature may` — Date: — v7
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
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0 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:
%i rl ti Gam.. (7(c ) 6// 0/9 / ( ft, ) 69 V 7‘
MAILING ADDRESS: p a ge r ((f$r c L riea dale EMAIL: Tl-H , c. ,4 I,C: 4.,1 ve L 4 S 4. . Ccn
CONTRACTOR'S LICENSE WAINS
NUMBER: /%-7,-7 c C g- /22 iy L NUMBER
ARCHITECT/ENGINEER: p.,,r_c1�.s PHONE O(c ) 3 7-7icL4 FAX: ( j6., ) 377 /ozL.
MAILING ADDRESS: /"O fi,.,, 691 7 i 1 1 c ra:,< ch-- i j EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
U'New 0--"Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: / Bank Height: ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: I CY(ndividual System
❑ Repair ❑ Masonry SEP Permit# 0 5-31,0
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: 6 _ Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ( - A-Public Total: f Name of System: /7,-1,4
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: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
EY'Underground Tank ❑ Above ground Tank Size of Propane Tank: d, G-it t
6YHeat Stove [y'Cook Stove ❑ Woodstove ❑ Fireplace Insert LYHot Water Tank ❑ Pellet Stove ❑ 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 %7 `c5033$ \i EH Bld App Review: { t;t-2115 .
Floor Heated ,' 4,t:i ' , Consistency Review: ..- ,I.
Other Heated Base fee: L
Mezzanine - Additional Section:
Heated Basement ` Plan Check fee: q 13
6iLJ
Unheated Basement State Surcharge fee: /' ' --)
Other Unheated Pot Water Review fee: 3 rO
Garage/Carport - SUBTOTAL
Decks 911/Rd Approach fee:
eXIS 1>�
Other TOTAL: $. AI 1Y!
Receipt Number: �`^< "'1�J 1 p
13.04-1 I Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: ��
.F et value of a r and materials foundation to finish
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