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HomeMy WebLinkAboutBLD2007-00107 • • 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 #: BLD07-00107 SITE ADDRESS: 7418 FLAGLER RD Issue Date: 02/20/2008 NORDLAND, 98358 Final Date: 11/17/2008 APPLICANT: JACOB J JOHNSON PHONE: 360-379-9769 7334 FLAGLER RD NORDLAND WA 983589664 SUBDIVISION: BE I IY HILLER SHORT PLAT Block: Lot: 1 PARCEL NUMBER: 021332035 Section: 33 Township: 30 N Range: 01 E PROJECT DESCRIPTION: NEW MAN HOME (GLEN RIVER 19860 - SERIAL# GR2048XY) THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: V'�n U-C-K C -�or-c cA r yOtryA, oV I l TYPE OF CONSTRUCTIO t ,\�� I+'15 �- N: SPRINKLER SYSTEM yes no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 11/17/2008 I:\F_BLD_Occupancy.rpt 10/29/19 • MANUFA URED/MOBILE HOME INSTA'I_LATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD07-00107 Received Date: 3/16/2007 SITE ADDRESS: 7418 FLAGLER RD Issue Date: 2/20/2008 NORDLAND, 98358 APPLICANT: JACOB J JOHNSON 7334 FLAGLER RD NORDLAND WA 983589664 SUBDIVISION: BETTY HILLER SHORT PLAT Block: Lot: 1 PARCEL#: 021332035 Section: 33 Township: 30 N Range: 01 E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: NEW MAN HOME (GLEN RIVER 19860 - BLD07-00107 MAKE: GLEN RIVER YEAR: 1986 SIZE: 56x28 Directions Simms Way/20 -straight onto Airport Cutoff Rd/19-onto Rhody Dr/19 -Left onto Ness Corner Rd/116-slight left To Site: on 116 -turn left onto 116/Flagler rd EXT THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 2/20/2009. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): __ -2,Arli ei� . //r SEraock Stormwater FINAL Approval: Ga-r-tEPS DewNsPc5:.rr5 q I « H 7t..rN8- Blocking/Plumbing: 5..6egl UC f !! - DCturp1 S i z/(oB Afr M64 0 ,1141 f Propane Tank/Lines A/f� Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval:Final/Skirting/Vents/Porches/Steps: oK - c- -tr,04,-I I I/7 T)i3 HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRI R TON INAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY-SEE REVERSE ILDING PERMIT APPLICATI MLA07-00132 Review Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00107 Received Date: 3/16/2007 SITE ADDRESS: 7418 FLAGLER RD NORDLAND, 98358 OWNER: JACOB J JOHNSON PHONE: 360-379-9769 7334 FLAGLER RD NORDLAND WA 983589664 BETTY HILLER SHORT PLAT SUBDIVISION: Block: Lot: 1 PARCEL NUMBER: 021332035 Section: 33 Township: 30 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW MAN HOME (GLEN RIVER 1986 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date/ !‘ / 0 7 Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $163.00 CJZ 03/15/07 89589 ADRcVE D Potable Water Application $58.00 CJZ 03/15/07 89589 Total: $221.00 FEB ao 2008 Jefferson County Planning &Building Department • SPECIAL CONDITIONS CASE # BLD07-00107 1.) PRIOR TO OCCUPANCY: FINAL APPROVAL OF SEPTIC SEP06-476 IS REQUIRED. 2.) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC TANK, RESERVE & DRAINFIELD. MUST COMPLY WITH ALL PERMIT CONDITIONS, STATE AND LOCAL CODE. 3.) A MINIMUM OF 5' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND EDGE PUMP CHAMBER & SEPTIC TANK. 4.) The application was reviewed by the Jefferson County Department of Community Development staff on April 27, 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: Category II Wetland at the NW corner of the parcel, Special Aquifer Recharge Protection Area and High Risk Seawater Intrusion Protection Zones (SIPZ). 5.) A Wetland Delineation Report dated July 200q prepared by Olympic Wetland Resources, !net was submitted in conjunction with the application to address the Wetlands. 6.) 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. 7.) 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. 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 (Sambucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium). 10.) Marine shorelines and islaniOre susceptible to a condition that is knowriseawater 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 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). 12.) A setback of 100-feet, measured perpendicularly from the wetland edge, shall be permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the wetland or its buffer is allowed. 13.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall contain the following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation." 14.) A permanent physical separation along the upland boundary of the wetland buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 15.) 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. 16.) 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. 17.) 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. IP • MANDATORY MEASURES FOR HIGH 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 , il 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 i' 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. 19.) The project shall adhere to the Best Management Practices(BMPs)to control stormwater, ' erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater 41 and drainage control systems. t 20.) The applicant is proposing to create or add 4228 square feet of impervious surface and �, 4228 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require the 41 project applicant submit a stormwater plan meeting Minimum Requirements#1 through#5 of the Department of Ecology Stormwater Management Manual for Western Washington. "1 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. Zq21.) A Stormwater Slte Plan for a 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 v7 inspect the property for plan compliance. A Certificate of Occupancy will not be issued --I 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. N 22.) 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). 23.) The revised site plan as submitted on April 1, 2007 and revised January 3, 2008 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated January 3, 2008 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 24.) This approval is for a Garage with no heta and no plumbing 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. 25.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 26.) 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. 27.) Minimum setback from the ingress/egress eament along the southern property line is 20 ft. Minimum side and rear setbacks are 5 ft. Environmentally Sensitive Areas further impact setback. 28.) Lighting fixtures shall be desled and hooded to prevent the light source. 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. 29.) 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. 30.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 31.) The building height is not to exceed 35 feet. 32.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 33.) Flagler Rd (SR 116) is a principal arterial. An easement of record provides access to the subject property. As part of the Better Hiller Short Plat, a county road approach permit was issued under permit#82-11-30-1. The road approach is existing and an address of 7418 Flagler Rd has been assigned to the parcel. 34.) A septic permit (SEP06-00476)was approved on January 9, 2007 for a system of 360 gallons per day. 35.) This parcel was created through the Bety Hiller Short Plat under AFN 285100, filed of record August 15, 1983 in Volume 2 of Short Plats, page 35 with Jefferson County Auditor's office. 36.) A minimum of two (2) on-site parking spaces are required for the single family residence. 37.) This parcel is served by a public water supply (PUD). JACK WVESTERMAN I. Jefferson Co. Courthouse ASSESSOR PO Ilex 1220. Port Townsend, WA 98368 (360)385-9105 MOBILE HOME INFORMATION FORM _.._. t. OWNER'S NAME/MAILING ADDRESS: u i NAME: __._iAc_v ___.Tcp1-0,4:3014" ADDRESS: 7334 GAL a k,-„,__A,,,, 1�.►`q_ � _a-8 PRONE NO. 'G'c) �-'7`i 5•7wc The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. ',MOBILE HOME DATA: (A) MAKE ULC11/4.1 -v-Ele-..„. (B) MODEL v22- ' L.,.D( )J (C) YEAR S4"/84- (D) LENGTH (E) WIDTH F)SERIAL# (G) YOUR PURCHASE PRICE (Do not include sales tax)45Off— PURCHASE DATE�r) 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE M )/ ADDRESS �) E� / (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY� LAST YEAR Yes) No If Yes, Previous address of mobile. ' c L e/ 17W If No, What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes '''--- (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: --C J/4 r3 �c3 1 of 3o� LOCATION ADDRESS �-ia -i,-��,e-�LEK ' - _pe.L/ A 1 .5 83- REAL PROPERTY PARCEL #/DESCRIPTION C1, ac '3-� THANK YOU FOR YOUR HELP! C5H JO COSSELL, Property Technician 0 V 01 CJ W N -+ • id .._ IIII 3 O ?1 < 0 -+ xi N m 1 m p N S `G ^ -, ° d N `< C G1 m .�1 J KIII a rt .r CO N 7 3 --1 I C x' co \ Al 1 a 0 t3 g p : p D . ' o •\ �� • m _ 7C a `D C! 3 • , csT rtp ; cD 3 1'�C, 3• 11: 3 ° ? �, t0 m. cu 4> :.• C p Iill a ii 62' ° ' xi� � a m H ..o O o :~ 7 C ?I p m N b O-�• i W. . :1 o S �! '• 7.:: F ID N �_ al 124 ':- .-1 M _ C r ' '. ..- o (a N p < a ti I x` G1 f• ' ` o _Al_ A i aI • Lo � • Q W — ; p xe Z • , 5i `6 m N C 6/ A p W N • S iv — - 3 Of 01 Amil N ; ;:'::7{': p ° O p• N _tO 0 o p d. N ' O .4 ' 04 . Lo7..II N E. WNaia D to ,'I ai 3 f7 =i C G w 1 0�Rt: .771 p �� , x' � . Z,. � � 3 � < y ci 1. �. • tD w C ( U a p p p v IIL__ _ - - _ � � p re 74' co cu N Nco till ZI MM cca /w sir Imeml O ca M. u V r M co, JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street• Port Townsend •Washington 98368 _ `q 4: 360/379-4450 • 360/379-4451 Fax www.co.jefferson.wa.us/commdevelopment 5 LJu7 Master Permit Application ;MLA: Q —1 - ( ! Project Description(include separate sheets as necessary): Tax Parcel r r Property Number. C) /, a ao� Size: e" J a '`�: es civare feet) Site Address and/or Directions to Property: l\,rN _ j`(d Property Owner(s)of Record: _1�ico8 c,�t,J- o Telephone: e- 5 -`5" Fax: 3` � 9 70 3 email: S2 Mailing Address: 7 33 4' v� b l�c��nc�►vf� 1 'A c.)Z a:8 Applicant/Agent(if different from owner): Telephone: a - C5 T? c 5 Fax:3G-c.) 3T7 - 7 7 0.3 email: /V f q Mailing Address: What kind of Permit?(Check each box that applies) Building ❑Variance(Minor,Major or Reasonable Economic Use) d Demolition Permit ❑Conditional Use[C(a),C(d),or C]-- d Single Family - °Discretionary"D"or Unnamed Use Classification ❑Special Use(Essential Public Facilities)** Manufactured Home °Boundary Line Adjustment d Modular CIShort Plat** ❑Commercial* °Binding Site Plan** Q Change of Use °Long Plat** °Address I Road Approach °Planned Rural Residential Development(PRRD)/Amendments** Q Propane ❑Plat Vacation/Alteration** °Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** °Stormwater Management ❑Shoreline Management Substantial Development** OSite 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: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application th h or she is pri r tice. Signature: Date: .-v.2 '‘.07) The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable resk sybility for as herin to nd complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: Date: / C7 D:\PennitCenter\FORMS\DRD 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 assuming the res onsibili the General Contractor for the proposed project. i SigRetn Imo/ Date:, -'� Cam)—Cam' ,..; MAR 1 5 230 i GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: V ( ) ( ) MAILING ADDRESS: EMAIL: r% b, CONTRACTOR'S LICENSE i I WAINS 4 NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New Wood Existing: 0 Sewer Addition 0 Steel Proposed: �2 Bank ❑Community System ❑ Alteration/Remodel 0 Concrete Total: _ Height: Individual System ❑ Repair ❑ Masonry -`i'7�14.— S P Permit# � `47� El Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: 'Private well 0 Two Party Type of Heat: Proposed: Public ,,r,,7 off, Total: _ 4 Name of System: 0 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 app1Y: CI Underground Tank 0 Above ground Tank Size of Propane Tank: ❑Heat Stove ❑Cook Stove ❑Woodstove ❑Fireplace Insert 0 Hot Water Tank 0 Pellet Stove In Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines,tank location and size, distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH Bld App Review / �.y.,� 2na Floor Heated Consistency Review. 153.W CC./ Other Heated Base fee: i (o3• GO Mezzanine Additional Section: _ Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: q 5.06 Garage/Carport SUBTOTAL 2l -1-1. co Decks 911/Rd Approach fee: Pnj t ZU Ur. Other TOTAL: $ /i '7'7 ceD Receipt Number: '6G`c$ Cash/Check Number: ag1 ESTIMATED COST(REQUIRED) Date: (� ( ��] .Fair market value of all labor and materials foundation to finish ( / Initials: C^ / D:\PemritCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc RETURN ADDRESS El?„744Za JSHINGTON MANUFACTURED HOME PLEASE(IIE('K ONL licEnsinG APPLICATION x TITLE ELIMINATION ❑TRANSFER IN LOCATION ❑REMOVAL FROM REAL PROPERTY Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a fine,imprisonment,or both. (RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) `/o5 -1i-ti-is fS3 61leAnr 5 b)cZ. L 12,ZOLM Y © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE x AFFIXED ❑REMOVED 021 332 035 LOT BLOCK Betty Hiller Short Plat QUARTER/QUARTER SECTION 1 ® GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS I I NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Jacob J.Johnson NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 7418 Flagler Rd. Nordland WA 98358 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Frontier Bank NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 2200 Sims Way Port Townsend WA 98368 GRANTEE NAME Jacob J.Johnson I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE T RE ISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APP v7 4t Signature of Additional Registered Owner and Title,IF .1\100Y4 V P,/STAMP ' NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE P N`t S M/T State of Washington Signed or attested `\\k� A/ ." County of Jefferson efo eon +�� • • j? t O1ARy \ Y by Jacob J.Johnson fgnature t inn 0 Z = PRINTED NAME OF REGISTERED OWNER TAi 13 O�G ••• ti — by 1 i P V g :• C? •� RINTED NAME OF REGISTERED OWNER NTED N OF NOTARY 7--y.,� % 11.•�'• • �� 'I-� County/Office No.O "7 I ]`IT) �/� n ••••••••'n� �� \�.' Title (+ , �j AND: Dealer No.OR C/ +� ` F W P`' \\\ D A SHIP PO IT N/AGENTMOTARY Notary Expiration Date /%/lEl ��l �11� lll�I1\��\\ TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER Jefferson Title Company (360)385-2000 SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. BUILDING PERMIT OFFICE CERTIFICATION I certify that: the manufactured home has been affixed to the real property as described. a building permit has been issued for this purpose and the attachment will be inspected yupon ncompletion. NA AAUt.. 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