HomeMy WebLinkAboutBLD2009-00150 0 Revviewiew T TyUILDING PERMIT APPLICAWN BL y150
pe:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00150 Received Date: 5/19/2009
SITE ADDRESS: 73 N PITTSBURG AVE
PORT TOWNSEND, 98368
OWNER: JASCHA KOZELISKY PHONE: 360-643-1876
912 S JACOB MILLER RD
PORT TOWNSEND WA 983689253
IRONDALE
SUBDIVISION: Block: 117 Lot: 10-11
PARCEL NUMBER: 962111704 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP PORCH ROOF
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 500.00 ADD'L: HEAT TYPE:
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: 60 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total:
Routinq Date:
Type Amount Paid By: Date: Receipt: AôVED
Permit $38.75 LYK 05/19/09 108489
Plan Check $25.19 LYK 05/19/09 108489
State Building Code $4.50 LYK 05/19/09 108489 MAY dci 2009
Total: $68.44 Jefferson County Planning
& Building Deaartmenr
Jefferson County Building Dlfsion Permit Nun.:
Applicant:
BUILDING PERMIT INSPECTION APPROVALS \pplicable Code: 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
FINAL INSPECTION Z„i
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
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1�4ri ca . JEFFERSON COUNTY
W DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368 MAY 1 9 2009
O0 360/379-4450 • 360/379-4451 Fax
SIN http://www.co.jefferson.wa.us/commdevelopment/
Stormwater Calculation Worksheet
MLA# PROJECT/APPLICANT NAME: t11-( C t. ..• 67 c !',()> C�
DETERMINING STORMWATER MANAGEMENT REQUIREMENTS: This stormwater calculation worksheet should be completed first
to classify the proposal as"small,""medium,"or"large." The size determines whether a Stormwater Site Plan is required in conjunction
with a stand-alone stormwater management permit application, building permit application, or other land use approval application that
involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required.
PARCEL SIZE(I.E.,SITE)
Size of parcel ±. 9____acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet / Lo / 00 sq/ft
Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover (both vegetative and
non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling,
excavation, and compaction associated with stabilization of structures and road construction.
Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the
Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as
Douglas fir,western hemlock,western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,
and salal; herbaceous plants such as sword fern,foam flower, and fireweed.
LAND DISTURBING ACTIVITY, CONVERSION OF NATIVE VEGETATION, AND VOLUME OF CUT/FILL
Calculate the total area to be cleared, graded,filled, Answer the following two questions related to
excavated, and/or compacted for proposed development conversion of native vegetation:
project. Include in this calculation the area to be cleared for:
Does the project convert'/4 acres or more of
Construction site for structures sq/ft native vegetation to lawn or landscaped areas?
Drainfield,septic tank,etc. sq/ft Circle: Yes
Well, utilities, etc. sq/ft Does the project convert 2'/z acres or more of
native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft
Circle: Yes No
Lawn, landscaping,etc. sq/ft
Other compacted surface, etc. _ sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance `, sq/ft Cut Fill (cu/yd)
[over]
stormwater calc worksheet—REV.11/3/2008
1
! •
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions
prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow
from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof
tops, walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen materials,
and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater.
STORMWATER CALULATIONS—IMPERVIOUS SURFACE
NEW 3O EXISTING G
Structures alCr�area) 'U sq/ft Structures(all roof area) C / /J sq/ft
Sidewalks sq/ft Sidewalks tJ 0 sq/ft
Patios sq/ft Patios sq/ft
Solid Decks sq/ft Solid Decks sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking, roads,etc sq/ft Driveway, parking, roads, etc L'I (.) 0 sq/ft
Other sq/ft Other sq/ft
Total New Ct' 0 sq/ft Total Existing -'?- Q3 Z sq/ft
TOTAL NEW+TOTAL EXISTING* 3 3 2_2- sq/ft "This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v. REDEVELOPMENT �
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: S. `j
�
Does the site have 35%or more of existing impervious surface? Circle: Yes No
FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be
used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the
attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum
Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements.
For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and
prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction
Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of"medium" projects—those
that must meet only Minimum Requirements #1 through #5—and for "large" projects—those that must meet all 10 Minimum
Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan,
principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or
prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual.
APPLICANT SIGNATURE
By signing the Stormwater Calculation 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 aff cted propert .
co..,13 _ / ?_ 0 1
(LANDOWNER 0 \HORIZED R -ESE TATIVE SIGNATURE) (DATE)
•- • i •NLY :;
- , • :F EDIUM . LARGE "REDEVELOPMENT` 'Stomiwa -r" itePlan. •`es ','
2
stormwater calc worksheet—REV.11/3/2008
/ _
(4.:- ON---c.oL JEFFERSON•OUNN •
,c ' ��� DEPARTMENT OF COMMUNITY DEVELOPMENT MAY 1 9 a
621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
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c3 www.co.jefferson.wa.us/commdevelopment
,\
Master Permit Application MLA: f"\ (j j r V LJ'1
Project Description (include separe sheets as necessary):
Tax Parcel Number: q (p Z I i ( 70 C i Property Size: (acres/square feet)
Site Address and/or Directions to Property:
It P) i-9 4-v--c-
Property Owner(s)of Record: '' � c-1.b%-c_ k?i- 1-)5 4
Telephone: 3 gc" (c Li S ---le 7Lr- Fax:
email:
Mailing Address: r-r 12. 5 . cC ‘`- ; I(. r�.41") t 7
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation
[i$uilding r/[ec• ;,r,. 0 Critical Areas Stewardship Plan
❑ Demolition Permit �"' ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]**
O Manufactured Home .0 Modular ❑ Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑ Special Use(Essential Public Facilities)**
❑ Change of Use ❑ Boundary Line Adjustment
❑ Address ❑ Road Approach ❑ Short Plat**
❑ Home Business ❑Cottage Industry ❑ Binding Site Plan**
❑ Propane ❑ Long Plat**
❑ Sign - ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑ Stormwater Management ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑ Temporary Use ❑ Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference 0 Tree Vegetation Request
**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).
---5OWNER 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 its 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 applicatioth�the o he wants prior notice. _ /L� p,
Signature: Date: r) ` 1 o /
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 responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date:
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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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 e r spo ibility of the General Contractor for the proposed project.
:
Signature: Date: .S -14l'--O 1
•
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE MAY 1 9 2009 WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New 'XWood Existing: 2 ❑ Sewer
yi Addition ❑ Steel Proposed: Bank i i Community System
❑ Alteration/Remodel ❑ Concrete Total: Z_ Height: )›individual System
❑ Repair ❑ Masonry SEP Permit#
O Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: I I Private well U Two Party
Proposed: Public
Type of Heat: Total: "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 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 . y EH Bld App Review: _
Floor Heated I Consistency Review: _
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement Plan Check fee: -2--S 0 \9
Unheated Basement State Surcharge fee:
S U
Other Unheated Pot Water Review fee:
aragearportCD c9 SUBTOTAL 6,, ,
--6 . ,Decks 911/Rd Approach fee: ___------
Other (? -4144 TOTAL: $ (z) s-•� Li
?cyCz.,1/N LOG Receipt Number: i CC6 4 r I
Cash/Check Number: Z \q
ESTIMATED COST(REQUIRED) Date: _`Ck _U
.Fair market value of all labor and materials foundation to finish
c Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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