HomeMy WebLinkAboutBLD2007-00541 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 #: BLD07-00541
SITE ADDRESS: 12 BLENHEIM PL Issue Date: 12/3/2007
PORT TOWNSEND, 98368 Final Date: 8/21/2008
APPLICANT: LUCINDA D BAMBURG PHONE: 425-644-2042
JERRY BAMBURG
6246 147TH AVE SE
BELLEVUE WA 980064358
SUBDIVISION: KALA POINT#4 Block: Lot:
PARCEL NUMBER: 965000070 Section: 27 Township: 30 N Range: 01 W
PROJECT DESCRIPTION: NSFR W/ATT GARAGE &A/G 120 GAL PROP TANK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2006 EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes no
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 8/21/2008
I:\F_BLD_Occupancy.rpt 10/29/19
MLA07-00579
titILDING PERMIT APPLICATION Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00541 Received Date: 10/15/2007
SITE ADDRESS: l l ZienIne m PI
PORT TOWNSEND, 98368
OWNER: LUCINDA D BAMBURG PHONE: 425-644-2042
JERRY BAMBURG
6246 147TH AVE SE
BELLEVUE WA 980064358 KALA POINT#4
SUBDIVISION: Block: Lot: 73
PARCEL NUMBER: 965000070 Section: 27 Township: 30 N Range: 01 W
CONTRACTOR: KELLEY SHIELDS INC PHONE: (360) 385-7156
260 KALA POINT DR
PORT TOWNSEND WA 98368
Contractor's License KELLES1150LF Expires 6/6/2009
REPRESENTATIVE: KELLEY SHIELDS INC PHONE: (360) 385-7156
DENNIS KELLEY
260 KALA POINT DR
PROJECT DESCRIPTION NSFR W/ATT GARAGE & A/G 120 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 2,930
VALUATION 304,920.00 ADD'L: HEAT TYPE: PRO
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N SHORELINE:
GARAGE: 816
CONST TYPE: DECK: 250 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: KALA PT
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 3
Total: 3 Vital: _.__3-
Routinq Date:
IU- In-C`1
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $2,141.75 LYK 10/15/07 95351 APPRJ\/EEJ
Plan Check $1,392.14 LYK 10/15/07 95351
State Building Code $4.50 LYK 10/15/07 95351 DEC 3
Potable Water Application $58.00 LYK 10/15/07 95351 z�07
Total: $3,596.39 Jefferson County Planning
&Building Department
Jefferson County Building Division Permit NumbiBLD07-00541
Applicant: BAMBURG
BUILDING PERMIT INSPECTION APPROVALS applicable 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 ��
S 4•A eace" /.IFFir DG th_Ag
Erosion Control
Foundation Footing ,a`- t�•c�`�`" qR r- 4- ono le_ics
4i7e4e&-- Lie 0-/aP�G
Footing Drains
Foundation Stem Wall I)-"'ie'4" 0-0`'�� n
Ate/Ve 6‘046 404 ViAr#
Under Floor Framing ja/3Vei
Straps(hold downs)
Ext. Shear Wall Nailing j l/l/O`�, t
Rough-in Plumbing ;124/d8
Framing 2/24/66 •
Blocking 04/4
� /l
Airseal 7//2
Insulation:Walls Lt—{�
Insulation: Floors
Insulation: Ceiling C�
Int. Shear Wall Nailing
Wallboard Nailing •3(Z 1(us
Gas Line: Interior Z/2 o.� GE_
Gas Line: Exterior R d tZ
Propane Tank ; L I }_ mac' (ct—
Heat/Chimney Clearance
Drywell/Alt Drainage
Address Posted
Aire ��J
— /� /1ca,0AL 6eAu paw Alia> - Poem>
FINAL INSPECTION =)(-O�fi
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD07-00541
1.) The application was reviewed by the Jefferson County Department of Community
Development staff on October 15, 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:
SARPA Aquifer Recharge Area.
2.) 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.
3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
4.) 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.
5.) 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.
6.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
7.) The parcel is located within an At Risk 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.
An At Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses between 100 mg/L and 200 mg/L (milligrams per liter).
8.) 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.
9.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
10.) The applicant is proposing to create or add 4450 square feet of impervious surface and
5100 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.
11.) A Stormwater Site Plan has been Onitted and approved by the Department o41/
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.
12.) 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).
13.) The site plan as submitted with theBuilding Permit application on October 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 November 13, 2007 shall be
resubmitted for review and approval by Jefferson County Department of Community
Development.
14.) This approval is for a Single Family Residence with attached garage and 120 gallon above
ground propane tank only. Any future permits on this site are subject to review for
consistency with applicable codes and ordinances and does not preclude review and
conditions which may be placed on future permits.
15.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
16.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
17.) 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.
18.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
19.) The building height is not to exceed 35 feet.
20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
21.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the
finished grade, excepting when such lighting is an integral part of a building or structure.
Ground level lighting is encouraged.
22.) Lighting fixtures shall be designed and hooded to prevent the light source from being
directly visible from outside the boundaries of the property. The intensity or brightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
23.) Minimum setback from Blenheim Place right-of way is 20 feet. Minimum setback from
Trafalgar Drive right-of way shall be 20 feet. Minimum west and south setbacks shall be 5
feet.
24.) Access Address is 12 Blenheim Place, Port Townsend. Blenheim Place is a private road
(P18).
25.) Potable water is provided by Kala Point public water system.
26.) The lot was created through the Kala Point#4 subdivison on June 12, 1978 under AFN
250653.
27.) A septic permit (SEP90-72)was cancelled on July 26, 1990 and filed with SEP98-136 that
was cancelled on July 30, 1998. A septic permit(SEP07-334)was approved on October
16, 2007.
• I
(.c5ONR cCIVED
,lt JEFFERSON COUNTY
ti DEPARTMENT OF COMMUNITY DEVELOPMENT OCT 1 5 2007
621 Sheridan Street• Port Townsend•Washington 98368
Is, As0,) 360/379-4450•360/379-4451 Fax JEFFERSON COUNTY OCO
SING http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# t J 1 i� f PROJECT/APPLICANT NAME: Cc.I'C FSuo
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.
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
U SE se -.
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
A -Q Lit-
4. Describe the existing soils. Indicate soil type on the site map.
SA'Lh 640,9rr t,., .
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. -�y
eiXGaE.G"i✓r Y/2f�►/,uP
6. describe any excess levels of noise generated by the proposed use or activity, f
/ APPROVED
STORMWATER PLAN
NOV 1 3 2007
sbrmwater site plan tempFate.doc rev.t0"2120€tormw er ' _
5
Required FER N u �Y
DEPT.OF ' , M TY D LO�I ENT
SIGNATURE: w n ``-/L
• •
7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map.
U41S.
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.).
n I—) 1 M Co of -r2 -e.c'ea ti c.T
t y )A r' / Nc? t i Tir C. C. /tr'�' '
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Permanent Stormwater Control Plan
OCT 13 2b(t
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. TY r
]"Medium' size projects are required to have the totals calculated of all impervious surfaces, lu � gRSe �� "
p pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
g. Describe the developed site hydrology,as proposed. Indicate whether stormwater will be fully dispersed(i.e., per BMP T5.30
in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities.
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W L V4 3 a 1)4 S Pelt-s igko v I "rw n 1) .y w et.4 ,
10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for large"projects or projects that involve the potential for dispersion of contaminants.]
11. Describe the performance goals and standards applicable to the project.
-- (.04a- itoel' 1)(c r? S a kt-t.. S7~'D ravor r 124,)A me
12. Describe the flow control system.
stormwater site plan template.doc—rev.10/122003
6
• •
13. Describe the water quality system. RECEIVED
OCT 15 2007
FERSDN COUNTY HD
14. Describe the conveyance system analysis and design.
15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
° G uT 1 Fi Lt. n 1= M f N t w, S,GNt M r CU
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.
— ajc 2 cK D ii 1.0 el C.a,—c4— , ROk,J 4 C,oh,G-
18. Describe methods for restoration of the site.
Lam►.► PS c i-t►k. ?sot- 148I T' rz• CD yr (LL"yvt S
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.
N +a--
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
W
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.
Cow
stormwater site plan template.doc—rev.10/12/2003
7
• •
CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN (SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consuft the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I—CONSTRUCTION$WPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
willto e bes adddre d. Identify the type and location of BMPs used to satisfy the required elemert-4 f an a�meq�'i�`ribtxa� bllh
proposal,justify in writing Descriptions of the 12 Elements are found at section 2.5.2 e1qr1'ual(1xegtnr(ng brit ' gig
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits. (l L ° s lr
Gn vk PLATE
In 9SO CO[ 1 9C[
2. Establish Construction Access.
P T CA-t=Y6rjZl
3. Control Flow Rates.
- PL)i i i"/ lr r C a k- t
4. Install Sediment Controls.
SP �r I •3
5. Stabilize Soils.
0(02_ TtvA c-. 4-q .
6. Protect Slopes.
SC-2T E-
7. Protect Drain Inlets.
Stormwater site plan templat.doc—rev.10/12/2003
8
• •
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
l/J 5 L P'eter- e3 Pefik l L—,_S —t`t
1 •
9. Control Pollutants.
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practices(BMPs).
OCT 15 2007
JE"ERSON COUNTY DCV--
12. Manage the Project.
1
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads).
Nt— 7c`7
fit= og,e. /
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
— 17(LA I r�y�=" G `tea t•1 u t.►,-1 fi Pir---" 'C4t 4 -
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
9/0 rd
stormwater site plan template.doc—rev.1011212003
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).
New Pn1-1-t,4
..
5. Construction Phasing. ri tr i '5 29111
a. Construction sequence
JEFFERSON COUNTY BCD
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
N O V t S - ,tee`t_y't - •5 1 ve5 F eh.< ate
vris 4�1i fro-e*s,f rlC1t..14- '.►T - Art tpt=
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
pc
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.
r2`i Ca rryr>! Fy u - P'n 1.44o w trZ` <.. i A4s-v
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
\L L ci.4- kan..pc c -Ae� '$ 401 />~.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions.
c. Waterways.
d. Runoff/Storrnwater Detention Calculations
sthrmwater site plan template.doc—rev.10/122003
10
• •
Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes, and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems, treatment facilities,flow control facilities,or structural source control BMPs
(not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best:of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property. t�``flfl
U r ` 1 �-�i�Q�
.01i /Zoo 7
(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) [
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
ECEIV �113
2107
JE iffiSt 1; ' [CO
stormwater site plan template.dx—rev.10/12/2003 t2
S* P/4/\J ,77Pea4
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pr + /or
�'oferg{ owner ''-,
Lot # 73 Jerrq and Lucinda[3amburq \ 1;,;, Contra '
� (leuu5hield5 Inc, .�� s ,,
Kala Point Ply. #4 6246 147 Ave. `` a
Sec 27-5r I/4 ON-IW Bellevue, WA 9i C%E.G E NE g1 nr 1'iop ►,, \.
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OCT 1 5 2007 K
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property Owner Cortractor
Lot # 73 Jerry and Lucinda 13am7urq Kelley Shields Inc.
Kala Point niv, 444 6246 147 Ave. 5; 260 Kala point Pr.
Sec 27-5F 1/ 4-50N-IW Bellevue, WA 98006 or Townsend, WA 9868
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SON c . JEFFERSO•OUNTY •
"`s j DEPARTMENT OF COMMUNITY DEVELOPMENT
`' ` `'d 621 Sheridan Street • Port Townsend -Washington 9'886
360/379-4450 • 360/379-4451 Fax
qs c$ www.co.jefferson.wa.us/commdevelopment
�tnv OCT 1 5 2007
Master Permit Application MLA: L)`7-..`_. !C1
Project Description(include separate sheets as necessary): r - �i {`j Cril
IQ cc,..) 51� t�61Lz, rti►4. t L
Tax Parcel Property
Number: q VS `0UU 010 Size: 15-toou . • (acres/square feet)
Site Address and/or Directions to Property:
c,',0 f2+Aart., o r --rwr p,i...cieV__ 4 Ppc..e4-)J-1-ey il.4 C-C' )U Or
Property Owner(s)of Record:
Telephone:4ZS-(64.4--. 41 2 Fax: email:
Mailing Address:4Z4lo 14-14P Ad a , 13e21.-tw V via- t kJ c a00c
Applicant/Agent(if different from owner): 1.4IEu Ems £ Wtp[ S - t g 1 a.r C,,
Telephone: 365-'115(-r Fax: '22 g 5 - 311 5 email:
Mailing Address: 2t0O 1G c,A PT- "L• I Pr /op,NSt tA,/.- ci 8 3 GCS
What kind of Permit?(Check each box that applies
❑Building 0 Variance (Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a),C(d),or Cl**
•R Single Family XGarage Attache Detached 0 Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home 0 Modular ` 0 Special Use(Essential Public Facilities)**
❑ Commercial* ❑ Boundary Line Adjustment
❑ Change of Use ❑ Short Plat**
❑ Address 0 Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry ❑ Long Plat**
'I Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
0 Stormwater Management 0 Shoreline Management Substantial Development**
❑Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment.
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
k I hereby designate tEL.(,e1 S!-fi r v S IN to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE ' Date: `CO1l j l?O 6 'j_ _ _
By signing this applicatio fo ,the owner/age attests that the information provid herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. ny material falseho d 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 r wants prior notices, 1
Signature: C /7 \ 7 Date: 1,6 I l''5 i two-7
The action or actions Appli ant ill undertake a result of the issuance of this perm t ay negatively impact upon one or more threatened or
endangered species and c ul lead to a potent I"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 res -bility for adhering to a t iiiplying with the A. The Applicant has read this discla er an signs and dates it below.
Signature: Date: it. 1 5 '-0 el 7
-. L
G:\PermitCenter\###FORMS ##\DRD FORMS\aster Permit Application 12-19-2006.doc
. BUILDER STATEMENT 4111
The signer of this statement does hereby certify that they are the Owners of the paI1cel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General C for for the proposed project.
Signature: Daten
k'w. L
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
14 y gn+'lWLi 5 /A/c-. �1: ftd)r:S.s5 -`1t5‘ (3f~o) 365-31I:3
MAILING ADDRESS: 2.W. )L .. P� , ,�� C t EMAIL:�1 JJ i J..S c O)Cz 64 P✓S. N
CONTRACTOR'S LICENSE WAINS
NUMBER: Lt S j /50 GF NUMBER
ARCHITECT/ENGINEER: t.4 u.DP,rfC• st44. „0„ „fej , PHONE (i(. ) ;t s••'6? SuFAx: ( )
MAILING ADDRESS: 'Qk72-jO,p`t' EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New `i1._ Wood Existing: ❑ Sewer
O Addition 0 Steel Proposed: z'/Z Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: 21/?_ Height: ❑ Individual System
❑ Repair ❑ Masonry iJ/f'- SEP Permit# 07-obi 3 ei-
O Demolition ❑ Other: Bedrooms: Water Supply:
Existing: X Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: J ❑ Public
Total: .-5 1" 4 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:
i Underground Tank Io.zdnelcmui• ewer. Size of Propane Tank: t [,.fit-•
H• eat 1.s. ook Stov I Woodstove I Fireplace Insert i Hot Water Tank I Pellet Stove i Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes U
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.
t tax -
-- . r r,;u a a
Square Footage Current Proposed `rrO'fri. ' U,74 ` ty� J -'; 111, At. ; Est ,.,.
Main Floor Heated ys f '' EH Bld App Review:
2n°Floor Heated ' ' Consistency Review: cc
Other Heated Base fee:
Mezzanine -, -i i Additional Section:
Heated Basement . . _ -,• Plan Check fee:
Iq� lq
Unheated Basement State Surcharge fee: ,
Other Unheated __ { Pot Water Review fee: (�`
Garage/Carport SUBTOTAL
Decks 2.6 ` Approach fee:
Other TOTAL: $Z✓C .31
Receipt Number:
''` 20 `cash/Check Number: 7J
ESTIMATED COST(REQUIRED) tvgi3 -e-- Date:.Fair market value of all labor and materials foundation to finish 10- in'Dr]
r]
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc