HomeMy WebLinkAboutBLD2008-00250 • •
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 #: BLD08-00250
SITE ADDRESS: 475 SNOW CREEK RD Issue Date: 08/15/2008
QUILCENE, 98376 Final Date: 8/26/2009
APPLICANT: MIKE PORTER PHONE: (425) 742-6637
DIANE L PORTER
6505 146TH ST SW
EDMONDS WA 98026-3523
SUBDIVISION Block: Lot: TX 38
PARCEL NUMBER: 802243011 Section: 24 Township: 28 N Range: 02 W
PROJECT DESCRIPTION: NEW MANUFACTURED HOME
MODEL - PACIFICA - nSer# H027905
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2006 EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 8/26/2009
I:\F_BLD_Occupancy rpt 10/29/19
MANUFACTURED/MOBIL URED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD08-00250 Received Date:
SITE ADDRESS: 475 SNOW CREEK RD 6/9/2008
QUILCENE, 98376 Issue Date: 8/15/2008
APPLICANT: MIKE PORTER
DIANE L PORTER
6505 146TH ST SW
SUBDIVISION: EDMONDS WA 98026-3523
Block: Lot: TX 38
PARCEL#: 802243011 Section: 24 Township: 28 N Range: 02 W
CONTRACTOR/ HERITAGE HOME CENTER PHONE: (425) 338-9055
DEALER MICHEAL MUGGE
10825 HWY 99
Contractor's License HERITHC930RM 2Expes512/14/2009
PROJECT DESCRIPTION: NEW MANUFACTURED HOME
MAKE: MARLETTE MODEL - PACIFICA
YEAR: 2008 SIZE: 60 X 27
Directions SEE GOOGLE MAP AND DIRECTIONS IN FILE
To Site:
THIS PERMIT IS VALID FOR ONE YEAR.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 8/15/2009.
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): '4j/�0�p Div) tc
1
Stormwater FINAL Approval:
Blocking/Plumbing:
Propane Tank/Lines
Zoning Final Approval:
Septic System Final Approval (If not on sewer):
Road Approach Final Approval: n
Final/Skirting/Vents/Porches/Steps: S�e-tho4 *114s ,-rime. dj( //43/c� 1? `i� r�
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL 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
•UILDING PERMIT APPLICAAN ML v Reviewiew T Ty 276
ype:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD08-00250 Received Date: 6/9/2008
SITE ADDRESS: 475 SNOW CREEK RD
QUILCENE, 98376
OWNER: MIKE PORTER PHONE: (425) 742-6637
DIANE L PORTER
6505 146TH ST SW
EDMONDS WA 98026-3523
SUBDIVISION: Block: Lot: TX 38
PARCEL NUMBER: 802243011 Section: 24 Township: 28 N Range: 02 W
CONTRACTOR: HERITAGE HOME CENTER PHONE: (425) 338-9055
MICHEAL MUGGE
10825 HWY 99
EVERETT WA 98204
Contractor's License HERITHC93ORM Expires 12/14/2009
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr NEW MANUFACTURED HOME
MODEL - PACIFICA
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 90,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2006 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: 2 Prop: 2
Total: 2 Total: 2
Routing Date:
LEI/o /
Type Amount Paid Bv: Date: Receipt: App_ro t
APPROVED
Manufactured Homes $168.00 KAS 06/09/08 'CO246
Potable Water Application $59.00 KAS 06/09/08 'CO246
Total: $227.00 AUG '.5 2008
Jefferson County Planning
&Building Department
• •
SPECIAL CONDITIONS CASE # BLD08-00250
1.) DESIGN CRITERIA FOR SPLASHBLOCKS:
A VEGETATED FLOWPATH OF AT LEAST 50 FEET SHOULD BE MAINTAINED
BETWEEN THE DISCHARGE POINT AND ANY PROP :RTY LINE, STRUCTURE,
STEEP SLOPE, STREAM, WETLAND, LAKE, OR OTHEER IMPERVIOUS SURFACE.
SENSITIVE AREA BUFFERS MAY COUNT TOWARD F:LOWPATH LENGTHS.
A MAXIMUM OF 700 SQUARE FEET OF ROOF AREA MAY DRAIN TO EACH
SPLASHBLOCK.
A SPLASHBLOCK OR A PAD OF CRUSHED ROCK (2 FEET WIDE BY 3 FEET LONG
BY 6 INCHES DEEP) SHOULD BE PLACED AT EACH DOWNSPOUT DISCHARGE
POINT.
NO EROSION OR FLOODING OF DOWNSTREAM PROPERTIES MAY RESULT.
FOR SITES WITH SEPTIC SYSTEMS, THE DISCHARGE POINT MUST BE
DOWNSLOPE OF THE PRIMARY AND RESERVE DR.AINFILED AREAS.
2.) CONSTRUCTION ENTRANCES SHALL BE STABILIZED WHEREVER TRAFFIC WILL
BE LEAVING A CONSTRUCTION SITE AND TRAVELING ON PAVED ROADS OR
OTHER PAVED AREAS WITHIN 1,000 FEET OF THE SITE.
THE ENTRANCE SHALL BE CONSTRUCTED ON A FIRM COMPACTED SUBGRADE.
QUARRY SPALLS (OR HOG FUEL) SHALL BE ADDED IF THE PAD IS NO LONGER IN
ACCORDANCE WITH THE SPECIFICATIONS. (BMP C105, 2005 DOE STORMWATER
MANUAL).
ANY SEDIMENT THAT IS TRACKED ONTO PAVEMENT SHALL BE REMOVED BY
SHOVELING OR STREET SWEEPING. THE SEDIMENT COLLECTED BY SWEEPING
SHALL BE REMOVED OR STABILIZED ON STIE.
ANY QUARRY SPALLS THAT ARE LOOSENED FROM THE PAD, WHICH END UP ON
THE ROADWAY SHALL BE REMOVED IMMEDIATELY.
UPON PROJECT COMPLETION AND SITE STABILIZATION, ALL CONSTRUCTION
ACCESSES INTENDED AS PERMANENT ACCESS FOR MAINTENANCE SHALL BE
PERMANENTLY STABILIZED.
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 OCCUPANCY & BUILDING FINAL- PRESSURE TEST OF SEP93-193 IS
REQUIRED INSTALLATION OF PUMP, CONTROL PANEL, RISER, FLOATS ETC.
REQUIRED PER SEPTIC PERMIT. REMIT PAYMENT OF TECHNICAL ASSISTANCE
FEE AND CONTACT JEFFERSON COUNTY ENVIRONMENTAL HEALTH TO
SCHEDULE PRESSURE TEST AT 360-385-9444 .
5 ) The application was reviewed by the Jefferson County Department of Community
Development staff on July 18, 2008 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 designation; eagle; rare plants; landslide 1; SUSC aquifer recharge
area.
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 rival portions of Jefferson County.
7.) Susceptible Aquifer Recharg•as are those with geologic and hydrologil,nditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
8.) 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.
9.) 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.
10.) The applicant is proposing to create or add 1808 square feet of impervious surface and
1800 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington 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 and drainage control systems.
11.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements#1 through #12 of the Department of Ecology's Stormwater Management
Manual for Western Washington 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 and drainage control systems.
12.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the subject permit has been issued the applicant shall
fully implement the provisions of the submitted plan and contact the Jefferson County
Department of Community Development to arrange a schedule to inspect the property for
plan compliance. A Certificate of Occupancy will not be issued until the Department
verifies plan compliance. No clearing for roadways or utilities shall occur on the project
site until clearing necessary for the installation of temporary sedimentation and erosion
control measures have been completed.
13.) 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).
14.) The site plan as submitted with the manufactured home installation application on June 9,
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 July 18, 2008 shall be
resubmitted for review and approval by Jefferson County Department of Community
Development.
15.) This approval is for a manufactured home installation 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.
16.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
18 ) 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.
19.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
20.) Residential developers and individual builders shall be required to preserve shoreline
vegetation and reduce the associated risk of erosion during construction and any future
activity which may impact the stability of the shoreline.
21.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
22.) Minimum setback from SnowSek Road right-of-way shall be 20 feet. Milum side
yard setbacks shall be 5 feet. Minimum setback from Lake Leland shall be 250 feet as
depicted on the submitted, approved site plan.
23.) 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.
24.) 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.
25.) The building height is not to exceed 35 feet.
26.) An address of 475 Snow Creek Road, Quilcene has been assigned to the parcel. Snow
Creek Road is a county local access (C352909).
27.) The parcel is served by an individual on-site well.
28.) A critical area review(CAR95-0151) for a garage was finaled on January 14, 2002. A
building permit(BLD95-0727) for a garage was finaled on May 20, 1996. A septic permit
(SEP93-0193)was finaled on November 3, 1995. A well review(USR06-0056)was
approved on June 20, 2006.
29.) The county mapps identify the proposed home to be located within a landslide hazard
area 1. The parcel appears to gradually slope down to the south to the lake. A
geotechnical report was not required for this project.
30.) The county Assessor's records identify an existing house on the parcel. Based on a site
visit on May 24, 2008 by Frank Benskin, Building Inspector, it was determined that this
structure is a garage with storage only and does not have plumbing and/or septic.
31.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat
management plan.
JACK IVESTEIIMAN • Jefferson it-,Courthouse
1
ASSESSOR • •
t ,i �" O B►�% 1'l'lll. Port Tonnsend,W:% 98:1671
4:160) 385-9105
MOBILE HOME INFORMATION FORM JUN —
9 2U08
OWNER'S NAME/MAILING ADDRESS:
NAME: rn \NNE.
ADDRESS: (OSO&- 4'b C.V(sAw rs WA- 1$132-.b
PHONE NO. 41s- i,Q Z- - total) 1
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.
1)MOBILE HOME DATA:
(A) MAKE Le-vw. (B) MODEL?I�-kVA.C-w1 (C) YEAR01VV
��s
(D) LENGTH (E) WIDTH � O (F) SERIAL #
(G) YOUR PURCHASE PRICE (Do not include sales tax)'vl C D 2 PURCHASE DATE
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
j
(A) FROM WHOM DID YOU PURCHASE MOBILE"E^� 1kvE. 1.-\oME C Yvvc. -
ADDRESS 10Szs EN e4IYLfEV\V 13‘4 E i ei-CT-C WANcuoifaaav
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No
If Yes, Previous address of mobile.
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 No
(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:. AY(€. Vk TSY\E. Q20( ��
LOCATION ADDRESS 41s 5v\AW C-AC <4N .\) VA 6,
REAL PROPERTY PARCEL #/DESCRIPTION E02_ 2_4-J ' V `\
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Signatur of pplicant
THANK YOU FOR YOUR HELP!
dl3-&J COSSELL, Property Technician
• •
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DEPARTMENT OF COMMUNITY DEVELOPMENT JUN - 9 2008
0.4 621 Sheridan Street• Port Townsend -Washington 98368
360/379-4450 . 360/379-4451 Fax r 1'
http://www.cojefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# PROJECT/APPLICANT NAME: \ \E 1 ti t:k .
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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3. Describe the existing vegetation. Indicate native vegetation areas on the site map. -
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4. Describe the existing soils. Indicate soil type on the site map.
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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: APPROVED
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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.
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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 existing facilities.
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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.]
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11. Describe the performance goals and standards applicable to thEi project.
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12. Describe the flow control system.
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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.
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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.
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20. List here and include any special reports or studies conducted to prepare the Stormwater 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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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 ail constriction 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 (BAAPN) 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 Blv1Ps used to satisfy the required element. If an element is not applicable
to the proposal,'justify in writing. f3:-.. pitons of the 12 Elements are found at section 2.52 of the Manual(beginning on page
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits.
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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.
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12 Required Elements-Construction SWPPP(contlnuecJ
8. Stabilize Channels and Outlets. _.
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10. Control De-Watering(theint of pumping groundwater or stormwater away from an active construction site).
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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).
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). Ui\A 6 1 � a es v C- S\ 1►�.
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site.
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b. Description of special requirements for working In or near environmentally sensitive areas.
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4. Erosion Problem Areas. Description of potential erosion problems on site in the context of.the characteristics of the on-site
soils(e.g.,erodibdity,settleability,permeability,depth,texture,soil structure).
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6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
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7. Financial/Ownership Responsibilities.
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impacts.
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8. Engineering Calculations. Provide Design Calculations on a separate shee tlW wrtngr if applicable.
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stormwater site plan template—rev.1 Wtl2003 10
40N,
ON C � JEFFERSOUNT11' ,
if `�� DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368 JUN 9 a....;
360/379-4450 • 360/379-4451 Fax
4qk starIN0�0 www.co.jefferson.wa.us/commdevelopment
C\ ....
Master Permit Application MLA: CA'a`il°
Project Description (include separate sheets as necessary):
I yv LL IMkkVw.. C-w1e h \''CD w-r€ W pe-VE V-- 4" E Lel-_ 4- S CP \L litrt\c- V'P
Tax Parcel /� Z4- Property
iU�Number: ' ?j — 0\ ( Size: 6 iol l'1` gUi) (acres/square feet)
Site Address and/or Directions to Property:
415 5wvv c, , vF-v) C v.`L.C..ekr €
Property Owner(s)of Record: V1'\VSE b-"V\1fNV\,� ' k/Z.7S- Z
Telephone: 4z-S- 142--bb3'] Fax: AZS-"3s3- 2V21 email:
Mailing Address: (oG0fa- " l 410 'T S cilwas W N 9 gp L(p
Applicant/Agent(if different from owner):
Telephone: Fax:ALS•1IS) 1(Z1 email: 5E-A k.ekx) b 7 wCi"( Itil:`C
Mailing Address:
Wh t kind of Permit?(Check each box that applies
uilding 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
f'Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
❑ Change of Use 0 Short Plat**
❑ Address ❑ Road Approach 0 Binding Site Plan**
❑ Home Business ❑ Cottagelndustry 0 Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign 0 Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save, indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs, reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
review and any required later inspections. Staffs access and right of ent ill be assumed unless the applicant informs the County in writing at the
time of the application that h or she wants prior notice.
Signature: • 10 (��(
Date:
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-tra sferabl respo ' Hiltfor adhering t' and complying with the . The Ap licant has read this disclaimer and signs and dates it below.
Signature: 1 c4.„-._ Date: S—k0 U g
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
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:
-Il,i al,Q-Cd mo qc ( MMe*"tt ,t. i+ CO-'C (�Lfr ��) �' 61Or75 (�{-�) _3 --5to 1
MAILING ADDRESS: i os 25 y CCj EMAIL:
CONTRACTORS LICENSE H G U i•1' Ic'?OP rn c9 ' ' WAINS CO
2_ X �0(p
NUMBER: h I'rl. J 1 NUMBER a p t l_
ARCHITECT/ENGINEER: PHONE ( '1"---' FAX: ( )
MAILING ADDRESS: EMAIL ,p
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
—New ,—Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: a Height: --ErTr'dividual System
❑ Repair ❑ Masonry SEP Permit# 0‘3 -0\°l 3
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: - Private well ❑ Two Party
Type of Heat: Proposed: a EllPublic
CAE( Total: a Name of System:lA.VM LU
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 i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove 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 / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed -For.Office;Use.Only• Amount . Revision ;.
Main Floor Heated i EH Bld App Review: rin IDO
2nd Floor Heated Consistency Review: )51•
Other Heated Base fee:
Mezzanine S
< s-„ ,, Additional Section:
Heated Basement Plan Check fee:
Unheated Basement �L/) f -,-. State Surcharge fee:
JJ J�JN -
Other Unheated D Pot Water Review fee: (1 s DO
Garage/Carport SUBTOTALAgo .D0
_L
Decks 0 911/Rd Approach fee:
Other o TOTAL: $ 4 ci d .00
Receipt Number: / 00a 4/6
Cash/Check Number: 5/q
ESTIMATED COST(REQUIRED) Date: 0/„ d C�
•Fair market value of all labor and materials foundation to fi i h 6 17 0
C / (j! to Initials: Cir
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
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