HomeMy WebLinkAboutBLD2007-00384 akUILDING PERMIT APPLICAl"J N M Review eviewT0384
Type:I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00384 Received Date: 7/18/2007
SITE ADDRESS: 505 SPIKE LN
OWNER: GLEN J HART JR PHONE:
KATHY A HART
505 SPIKE LN
FORKS WA 983319510
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 612042006 Section: 4 Township: 26 N Range: 12 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NSFR W/ATT GARAGE & U/G 30 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2,040
VALUATION 222,631.00 ADD'L: HEAT TYPE: WOD
CODE EDITION: 2006 HEAT BASE: HEAT TYPE: EEE
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: 672 SHORELINE:
CONST TYPE: DECK: 1,016 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 2
Total: 2 Total: 2
Routing Date: L
1 :g10
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,682.55 LYK 07/18/07 91385 APPROVEDPlan Check $1,093.66 LYK 07/18/07 91385
State Building Code $4.50 LYK 07/18/07 91385
Jr-
Potable Water Application $58.00 LYK 07/18/07 91385
Total: $2,838.71 Jefferson County pJBe�ng
& Building Department
Jefferson County Building Dition Permit Nur : BLD07-00384
Applicant: HART JR
BUILDING PERMIT INSPECTION APPROVALS \pplicable Code: 2006 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 1.it-01 v
Erosion Control .n
Foundation Footing j, 21-0''1 !. W
Footing Drains ww�l
Foundation Stem Wall 9,2,7_01 „ .Q
Under Floor Framing S. og
Straps(hold downs)
if�Q-to ikk�
Ext. Shear Wall Nailing It ,2,651 _ tp tw F�
Rough-in Plumbing c
Framing
(1-Z4' - `o IAA ►�
Blocking
Airseal It_.Z�„ to 11, (ti I�
Insulation:Walls
Insulation: Floors it - Ott
Insulation: Ceiling (I`M 4
Int. Shear Wall Nailing
I t -Z-et )u(4
Wallboard Nailing _ . o Wt (4-
Gas Line: Interior _24_ O UM 1�
Gas Line: Exterior
Propane Tank
Heat/Chimney Clearance
Drywell/Alt Drainage
Address Posted 1 1_2A_10
FINAL INSPECTION •I 2 g-I 0
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
•
CONDITIONS for Building Permit# :BLD07-00384
1.) A MINIMUM OF 10' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND
EDGE OF DISPOSAL COMPONENT & RESERVE AREA.
2.) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC
TANK, RESERVE & DRAINFIELD.
3.) 10' SEPARATION REQUIRED BETWEEN A WATER LINE AND ALL PORTIONS OF
THE ONSITE SEWAGE SYSTEM; EFFLUENT TRANSPORT LINE, TANKS,
TREATMENT AND DISPOSAL COMPONENTS.
4.) PRIOR TO FINAL BUILDING INSPECTION MUST SUBMIT RECORDED NOTICE TO
TITLE REGARDING THE SQUARE FOOTAGE OF HOME AND LIMITED CAPACITY OF
DRAINFIELD.
5.) The application was reviewed by the Jefferson County Department of Community
Development staff on August 13, 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, the following ESAs were
confirmed to be present on the subject property: Harlequin Duck Habitat, Frequently
Flooded Area.
6.) Jefferson County has determined that the use of real property for agriculture and forestry
operations is a high priority and favored use in the county. The county will not consider to
be a nuisance those inconveniences or discomforts arising from such operations, if such
operations are consistent with commonly accepted best management practices in
compliance with local, state, and federal laws. If your real property includes or is within
five hundred (500) feet of real property designated as Rural Residential 1:10 or 1:20,
Rural Industrial, Rural Commercial, Agriculture, or Forestry, you may be subject to
inconveniences or discomforts arising from such farming and forestry operations,
including but not limited to noise, tree removal, odors, flies, fumes, dust, smoke, the
operation of farm and forestry machinery during any 24-hour period, the storage and
disposal or manure, and the application of permitted fertilizers and permitted pesticides.
One or more of these inconveniences may occur as a result of agricultural and forestry
operations which are in conformance with existing laws and regulations.
7.) The applicant is proposing to create or add 5,328 square feet of impervious surface and
3,728 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.
8.) A stormwater 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.
9.) 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).
10.) The site plan as submitted with the building permit application on July 18, 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 August 13, 2007 shall be resubmitted for review
and approval by Jefferson County Department of Community Development.
11.) 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.
12.) The parcel has been designated as RR 1:20 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
13.) Outdoor residential storage shall maintained in an orderly manner and sha ate no
fire, safety, health or sanitary hazard.
14.) 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.
15.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
16.) The building height is not to exceed 35 feet.
17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
18.) Exterior lighting for residential uses shall not exceed twenty feet (20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
19.) Setback from Spike Lane right-of-way is no less than 20 ft., side setbacks are no less than
5 ft. The rear property line abuts a parcel zoned Commercial Forest which requires no
less than a 250 ft. building setback. If an environmentally sensitive area (ESA) is present,
then the more restrictive setback shall apply.
20.) Spike Lane (P560) is a private local access road. A road approach permit is not required.
An address of 195 Spike Lane has been assigned to the parcel.
21.) Stormwater shall be retained and infiltrated on site. The owner shall control all
sedimentation and erosion on the property.
22.) A"Construction Drawing" Flood Elevation Certificate was prepared by a licensed surveyor
and submitted with the application. The Certificate identified the base flood elevation of
151.1 TO 155.7 feet. The lowest floor of the structure is required to be elevated at least
one (1) foot above base flood elevation or 156.7 feet. PRIOR TO FINAL BUILDING
INSPECTION, PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN
ORIGINAL "FINISHED" CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT
HAS BEEN VERIFIED BY A LAND SURVEYOR, ENGINEER, OR ARCHITECT
AUTHORIZED BY LAW TO CERTIFY ELEVATION INFORMATION IN THE STATE OF
WASHINGTON.
23.) Flood hazard reduction measures are to be used as required by the Jefferson County
Flood Damage Prevention Ordinance 07-0515-06 (Jefferson County Code Chapter
15.15).
24.) Construction Materials and Methods of Construction to Reduce Flood Hazard
(i)All new construction and substantial improvements shall be constructed with materials
and utility equipment resistant to flood damage.
(ii)All new construction and substantial improvements shall be constructed using methods
and practices that minimize flood damage.
(iii) Electrical, heating, ventilation, plumbing, and air-conditioning equipment and other
service facilities shall be designed and/or otherwise elevated or located so as to prevent
water from entering or accumulating within the components during conditions of flooding.
Locating such equipment below the base flood elevation may cause annual flood
insurance premiums to be increased.
25.) New construction and substantial improvement of any residential structure shall have the
lowest floor, including basement, elevated one foot or more above the base flood
elevation (BFE).
26.) Fully enclosed areas below the l•st floor that are subject to flooding are prated
unless designed to automatically equalize hydrostatic flood forces on exterior walls by
allowing for the entry and exit of floodwater. Designs for meeting this requirement must
either be certified by a registered professional engineer or architect or must meet or
exceed the following criteria: a. A minimum of two openings having a total net area of not
less than one square inch for every square foot of enclosed area subject to flooding shall
be provided. b. The bottom of all openings shall be no higher than one foot above grade.
c. Openings may be equipt with screens, louvers, or other coverings or devices provided
that they permit the automatic entry and exit of floodwater.
27.) Utilities shall be designed as specified in 15.15.080(c) of Jefferson County Flood Damage
Prevention Ordinance 07-0515-06 (Jefferson County Code Chapter 15.15)which states:
(i)All new and replacement water supply systems shall be designed to minimize or
eliminate infiltration of flood waters into the systems; (ii) Water wells shall be located on
high ground that is not in the floodway; (iii) New and replacement sanitary sewage
systems shall be designed to minimize or eliminate infiltration of flood waters into the
systems and discharges from the systems into flood waters; (iv) Onsite waste disposal
systems shall be located to avoid impairment to them or contamination from them during
flooding.
28.) 1) All new construction and substantial improvements shall be anchored to prevent
flotation, collapse, or lateral movement of the structure.
2) All manufactured homes shall be anchored to prevent flotation, collapse, or lateral
movement, and shall be installed using methods and practices that minimize flood
damage. Anchoring methods may include, but are not limited to, use of over-the top or
frame ties to ground anchors.
29.) This parcel was created through "Hoh River Joint Venture" Survey under AFN 336893,
recorded December 13, 1990, Volume 11, page 268 with the Jefferson County Auditor's
office.
30.) A Declaration of Restrictive Covenant was recorded August 16, 2007 under AFN 526433
with the Jefferson County Auditor regarding septic capacity.
• •
,,ii off, JEFFERSON COUNTY ' 1? '1 \' 1 ��11
al
k' ' \\t A DEPARTMENT OF COMMUNITY DEVEL PM NT
ti '. , '4 621 Sheridan Street• Port Townsend •Washington 98368
360/379 4450 • 360/379-4451 Fax 2007
�q�IIINo� www.co.jefferson.wa.us/commdevelopment JUL i
Master Permit Application , ,rm. ,, :,,461,41 i Orl-- 24cLo
t
Project Description(include separate sheets as necessary): �/W�_ _I 9_ i l.C. . �tr6444
Tax Parcel Property
Number: 6,1 2 04 2 0(9 6, II Size: 5.12 6cre)square feet)
Site Address and/or Directions to Property: 505 �' Ike 1- ) Fcylcs,1 V " 9 833I
Property Owner(s)of Record: Vtt IA
Telephone: Gov- 3-7�-- en 1 F : email:
Mailing Address: 505 S1::1 lec La.A.A, 't W A 18331
Applicant/Agent(if different from owner): --te_ Lr sc.!,,Nii-e. ems, ) lNc•
Telephone: LeO-"2727-1,3ij0 Fax: 132?-33 SO email:-.kv vt.s ckli.c C.a..ti�E-c.v a.NLt
Mailing Address: i3O)( l✓eitAk�L_W A 6l8',O rj 1
What kind of Permit?(Check each box that applies)
Building ❑Variance(Minor,Major or Reasonable Economic Use)
i Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
n Single Fa it ODiscretionary"D"or Unnamed Use Classification
E arageched •etached OSpecial Use(Essential Public Facilities)**
• Manufactured Home °Boundary Line Adjustment
d Modular °Short Plat**
Q Commercial* °Binding Site Plan**
Q Change of Use °Long Plat**
Q Address i Road Approach °Planned Rural Residential Development(PRRD)/Amendments**
R Propane ❑Plat Vacation/Alteration**
DAllowed"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
OWireless Telecommunication* OJefferson County Shoreline Master Program Amendment
❑Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
( DESIGNATION OF AGENT
I hereby designate ((}} t\Ue.�.eeiov\ to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE K ctk L (- t-\c,--,:k Date: 0-7 / CI 7
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 requir t r inspect s. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the applica' n tha grie poor notice. u
Signature: t' Date: n-"1 __IOW- 01
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-transferablele eresponsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: f- .. 1.�0 �{�� Date: 7-q-n 7
D:\PeimitCenter\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 responsibility of the General Contractor for the proposed project.
Signature: K Cv (;, . Date: 7 —9-v
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
PS, New Wood Existing: _ ❑Sewer
❑ Addition Steel Proposed: 2. Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: -Z. Height: 1,71 Individual System
❑ Repair 0 Masonry SEP Permit# ai- (rr
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: Z.Private well 0 Two Party
Type of Heat: - Proposed: Z 0 Public
V,itb4 Total: Z Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
'Underground Tank Above ground Tank Size of Propane Tank:_ 3c.)v
0 Heat Stove PCook Stove IKWoodstove ❑Fireplace Insert Hot Water Tank 0 Pellet Stove p Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only, Amount .:Revision
Main Floor Heated ''4O EH Bld App Review:
2nd Floor Head Consistency Review: l ii '
.�
Other Heated Base fee: /-P--d:•
Mezzanine Additional Section:
Heated Basement Plan Check fee: ( ��.3•c(e
Unheated Basement State Surcharge fee: 1 Z1 Q
Other Unheated Pot Water Review fee: 613
Garage/CarportnG12 I� ST °4' SUBTOTAL ii
Decks On 1 D l� q ita 911/Rd Approach fee: �-
Y L +• n.
Other TOTAL: ,= "q4
6.3 1 3p .eceipt Number: q f 1 F5
I Cash/Check Number: O
ESTIMATED COST(REQUIRED) Date: I
.Fair market value of all labor and materials foundation to finish 11.
4'i 00^00�^ ' Initials: L
Cs. -5
D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc
U.S.DEPARTMENT OF HOMELAND SECURE. ELEVATION CERTIFICATE* OMB No. 1660-0008
Federal Emergency Management Agency I Expires March 31,2012
National Flood Insurance Program Important: Read theinstructions on pages 1-9.
SECTION A-PROPERTY INFORMATION For insurance Comprtt.kgt
Al. Building Owner's Name Jim Hart Policy N'ombe , n u '
A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIL Number 505 Spike Lane
City Forks State WA ZIP Code 983311.
A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.)
E1/2 E1/2 N1/2 SE1/4 NW1/4 Section 4,T26N,R12W,W.M.,Jefferson County Tax#612042006
A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Residential
A5. Latitude/Longitude:Lat. N 47-47-22 Long. 124-15-53 Horizontal Datum: ❑ NAD 1927 ❑ NAD 1983
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance.
A7. Building Diagram Number 9
A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage:
a) Square footage of crawlspace or enclosure(s) 2400 sq ft a) Square footage of attached garage 675 sq ft
b) No.of permanent flood openings in the crawlspace or b) No.of permanent flood openings in the attached garage
enclosure(s)within 1.0 foot above adjacent grade 30' within 1.0 foot above adjacent grade 0
c) Total net area of flood openings in A8.b 2520 sq in c) Total net area of flood openings in A9.b 0 sq i
d) Engineered flood openings? ❑ Yes ElNo d) Engineered flood openings? 0 Yes ® No n
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP Community Name&Community Number B2.County Name 83.State I
Unincorporated Jefferson County 530069 0575 575 of 1625 Jefferson I WA
B4.Map/Panel Number B5.Suffix B6.FIRM Index B7. FIRM Panel 88. Flood B9 Base Flood Elevation(s)(Zone
530069 0575 B Date Effective/Revised Date Zone(s) AO,use base flood depth)
7/19/82 7/19/82 A 151.1'to 155.T
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9.
❑ FIS Profile ❑ FIRM 0 Community Determined ® Other(Describe)WSDOT by Herrera Environmental Consultants 7/04
B11. Indicate elevation datum used for BFE in Item 69: ❑ NGVD 1929 ® NAVD 1988 0 Other(Describe)
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes Designation Date ❑ CBRS ❑ OPA ® No
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
Cl. Building elevations are based on: ❑ Construction Drawings' ❑ Building Under Construction` ® Finished Construction
'A new Elevation Certificate will be required when construction of the building is complete.
C2. Elevations-Zones Al-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO. Complete Items C2.a-h
below according to the building diagram specified in Item A7. Use the same datum as the BFE.
Benchmark Utilized Y-473-1974 Vertical Datum 186.95'NGS-NAVD88
Conversion/Comments 0
Check the measurement used.
a) Top of bottom floor(including basement,crawlspace,or enclosure floor)175.64 0 feet 0 meters(Puerto Rico only)
b) Top of the next higher floor 177.20 ®feet ❑meters(Puerto Rico only)
c) Bottom of the lowest horizontal structural member(V Zones only) na._ ❑feet ❑meters(Puerto Rico only)
d) Attached garage(top of slab) 175.66 ®feet ❑meters(Puerto Rico only)
e) Lowest elevation of machinery or equipment servicing the building 177.20 0 feet ❑meters(Puerto Rico only)
(Describe type of equipment and location in Comments)
f) Lowest adjacent(finished)grade next to building(LAG) 175.35 0 feet ❑meters(Puerto Rico only)
g) Highest adjacent(finished)grade next to building(HAG) 175.64 0 feet ❑meters(Puerto Rico only)
h) Lowest adjacent grade at lowest elevation of deck or stairs,including na._ ❑feet ❑meters(Puerto Rico only)
structural support
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION
This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation ,,, , mum.1 All a I IIMUIM...If, I
information. /certify that the information on this Certificate represents my best efforts to interpret the data available./ a _ :41", Y
understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001.❑ ? Q
Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a ? c /p O Sy� '�
S.
licensed land surveyor? 0 Yes ❑ No 'f C7 4 . 'i"-ti ,''•1 •'
Certifiers Name Dan P.Kousbaugh 5v. ii.;9 r I
License Number RLS 11983 x J
\ x;' ISO Title President Company Name Dan Kousbaugh Surveying,Inc.,P.S. 1.
\ •
,q +Q 11985 tO;'asv
Address 450 Spruce Drive CityForks ,, ISk /ST.. f dQ
X)//,)41
State WA ZIP Code 98331 - !i..4�A�OSSignature p /r �ii,4Date 11/16/10 Telephone (360)374-5720 ii
= -
ll� (6 /lc)
IMPORTANT: In these spaces,copy the corresponding information from Section A. For Insurance Company Use
Building Street Address(including Apt.,Unit,Su"/or Bldg.No.)or P.O.Route and Box No. Policy Number S `
505 Spike Lane
City Forks State WA ZIP Code 98331 Company NAIC Number
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner.
Comments On the morning of October 215`,2010,I visited this homesite and utilizing TBM#3 established June 6,2000(elev. 175.35') determined the finish
floor elevation of the new home to be 177.20'which is well above the county established number of 156.7'as shown on building permit number
BLDO -00384 under item number 22.
Signature Date 10/25/10
0 Check here if attachments
SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE),complete Items El-E5_ If the Certificate is intended to support a LOMA or LOMR-F request,complete Sections A,B,
and C. For Items El-E4,use natural grade,if available. Check the measurement used. In Puerto Rico only,enter meters.
El. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade(HAG)and the lowest adjacent grade(LAG).
a)Top of bottom floor(including basement,crawlspace,or enclosure)is ❑feet ❑meters 0 above or 0 below the HAG.
b)Top of bottom floor(including basement,crawlspace,or enclosure)is ❑feet ❑meters ❑above or❑ below the LAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor
(elevation C2-b in the diagrams)of the building is ❑feet ❑meters ❑above or ❑below the HAG.
E3. Attached garage(top of slab)is ❑feet 0 meters 0 above or 0 below the HAG.
E4. Top of platform of machinery and/or equipment servicing the building is ❑feet ❑meters 0 above or 0 below the HAG.
E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management
ordinance'? El Yes ❑ No ❑ Unknown. The local official must certify this information in Section G.
SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE)
or Zone AO must sign here. The statements in Sections A,B,and E are correct to the best of my knowledge_
Property Owner's or Owner's Authorized Representative's Name
Dan Kousbaugh
Address 450 Spruce Drive City Forks State WA ZIP Code 98331
Signature 521 ,/1 n )e� ' , ^�, Date 10/25/10 Telephone (360)374-5720
Comments Finish floor elevation of 177.20'meets or xceeds building department requirement of 156.T
❑Check here if attachments
SECTION G-COMMUNITY INFORMATION(OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),
and G of this Elevation Certificate. Complete the applicable item(s)and sign below. Check the measurement used in Items G8 and G9.
G1., ' The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who
is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)
G2. ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO.
G3. ❑ The following information(Items G4-G9)is provided for community floodplain management purposes.
G4.P it Number G5. Date Permit Issued G6. Date Certifica e Of CoT pliance/Occupancy Issued
'46L.D 0'7 oo3g ( S6aq/aoa -7 dt/z9( zoi 0
G7. This permit has been issued for: ,'New Construction ❑Substantial Improvement
G8. Elevation of as-built lowest floor(including basement)of the building:05.64 94 feet ❑meters(PR)Datum
G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters(PR)Datum
G10. Community's design flood elevation ❑feet ❑meters(PR)Datum
STINcriE }to&I -tr1S PI-P1414irty PVT-Jc
Local fficial's Name Title
tb 36,0-319-4MSO
Comm i ity Name Telephone
►t)3o1Zom
Si ature Date
Comments
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