HomeMy WebLinkAboutBLD2010-00252 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
Al Scalf, Building Official
PERMIT #: BLD10-00252
SITE ADDRESS: 187 BENTLEY PL Issue Date: 09/9/2010
PORT TOWNSEND, 98368 Final Date: 11/2/2010
APPLICANT: CURTIS M ELLIOTT PHONE: 360-301-0177
PO BOX 864
PORT HADLOCK WA 983390864
SUBDIVISION: LUNDSTROM'S ADDITION Block: 2 Lot: 1-10
PARCEL NUMBER: 969600201 Section: 24 Township: 29 N Range: 02 W
PROJECT DESCRIPTION: NEW M/H
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING
CODE 2009 EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes �o
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 11/2/2010
I:\F_BLD_Occupancy.rpt 10/29/19
MANUFACTURED/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 #: BLD10-00252 Received Date: 7/15/2010
SITE ADDRESS: 187 BENTLEY PL Issue Date: 9/9/2010
PORT TOWNSEND, 98368
APPLICANT: CURTIS M ELLIOTT
PO BOX 864
PORT HADLOCK WA 983390864
SUBDIVISION: LUNDSTROM'S ADDITION Block: 2 Lot: 1-10
PARCEL#: 969600201 Section: 24 Township: 29 N Range: 02 W
CONTRACTOR/ BUY RITE HOMES PHONE: (360) 681-0777
DEALER 259403 HWY 101
SEQUIM WA 98382
(360) 381-0780
Contractor's License BUYRIH*0840B Expires 5/20/2012
PROJECT DESCRIPTION: NEW M/H
MAKE: KARSTEN YEAR: 2007 SIZE: 56X28
Directions
To Site:
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 C�_�3 _(C Minimum setback from Bentley Place right-of-way shall be 20 feet.
Minimum side yard setbacks shall be 5 feet. Minimum rear setback
(commercial forest lands adjacent)shall be 70 feet.
Erosion Control SEE CONDITION 3
MH Foundation _ J o .L�
Blocking&Tie Down t._�� — in Q
Skirting&Ventilation
Gas Line: Exterior
Propane Tank
Pressure Test
Drywell/Alt Drainage SEE CONDITION 2 FOR SPLASHBLOCKS
Address Posted
t\A t S e /VC) N 424Z \Qxt utik, n- kz L ST-Au-6s
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS Ai-PLY -SEE REVERSE
•UILDING PERMIT APPLICAS)N ML
Revviewiew T Ty275
ype:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD10-00252 Received Date: 7/15/2010
SITE ADDRESS: 187 BENTLEY PL
PORT TOWNSEND, 98368
OWNER: CURTIS M ELLIOTT PHONE: 360-301-0177
PO BOX 864
PORT HADLOCK WA 983390864
LUNDSTROM'S ADDITION
SUBDIVISION: Block: 2 Lot 1-10
PARCEL NUMBER: 969600201 Section: 24 Township: 29 N Range: 02 W
CONTRACTOR: BUY RITE HOMES PHONE: (360) 681-0777
259403 HWY 101
SEQUIM WA 98382
Contractor's License BUYRIH*0840B Expires 7/13/2010
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI' NEW M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,500
VALUATION ADD'L: HEAT TYPE: EEE
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: 32 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 . _2
Total: 3 -JTotal: 2
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 07/15/10 117982 APPROVED
Potable Water Application $98.00 LYK 07/15/10 117982
Total: $311.00 SEP/, 2O1U
Jefferson County Planning
R. Riiildinn flonartmont
• •
SPECIAL CONDITIONS CASE # BLD10-00252
1.) A MINIMUM OF A 10' SEPARATION IS REQUIRED BETWEEN THE WATER LINE AND
ALL COMPONENTS OF THE ONSITE SEWAGE SYSTEM.
2.) DESIGN CRITERIA FOR SPLASH BLOCKS:
A VEGETATED FLOWPATH OF AT LEAST 50 FEET SHOULD BE MAINTAINED
BETWEEN THE DISCHARGE POINT AND ANY PROPERTY LINE, STRUCTURE,
STEEP SLOPE, STREAM, WETLAND, LAKE, OR OTHER IMPERVIOUS SURFACE.
SENSITIVE AREA BUFFERS MAY COUNT TOWARD FLOWPATH 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 DRAINFILED AREAS.
3.) 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.
4.) The application was reviewed by the Jefferson County Department of Community
Development staff on August 13, 2010 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: slight
landslide hazard area; coastal SIPZ.
5.) 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.
6.) Marine shorelines and islan•e susceptible to a condition that is knownikeawater
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 a coastal 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.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
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.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
10.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
11.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
12.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
13.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
14.) Landslide Hazard Areas and associated buffers shall remain naturallyketated.
Should buffer disturbance occur during construction, the Unified Development Code
(UDC)Administrator shall require replanting with native vegetation. No alterations shall be
made to the Landslide Hazard Area or its associated buffer without prior authorization by
the UDC Administrator.
15.) Prior to and during approved construction activities, the perimeter of the landslide hazard
area buffer shall be marked with a temporary sign. The sign shall be placed in such a
manner that it can be directly observed from the construction area. The sign shall contain
the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter
Existing Vegetation."
16.) All construction activities shall not encroach upon the landslide hazared area buffer. This
includes the storage or preparation of materials.
17.) The applicant shall permanently separate the boundary of the Landslide Hazard Area
Buffer from the remainder of the subject property through installing logs, trees, a hedge
row, or any other prominent physical marking approved by the UDC Administrator.
18.) The applicant is proposing to create or add 1568 square feet of impervious surface and
1500 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.
19.) 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.
20.) 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).
21.) The revised site plan dated August 3, 2010 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 September 8, 2010 shall be resubmitted for review and approval by
Jefferson County Department of Community Development.
22.) This approval is for a manufactured home 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.
23.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
24.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
25.) 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 automobile 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 requirements 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.
26.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
27.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
28.) The building height is not to exceed 35 feet.
29.) Minimum setback from Bentley Place right-of-way shall be 20 feet. Minimum side yard
setbacks shall be 5 feet. Minimum rear setback (commercial forest lands adjacent) shall
be 70 feet. If an ESA is present, then the more stricter setback(s) shall apply.
30.) 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.
31.) Lighting fixtures shall be desilt and hooded to prevent the light source lip being
directly visible from outside the boundaries of the property. The intensity or rightness of
all lighting, during construction and after project completion shall not adversely affect the
use of surrounding properties or adjoining rights-of-way.
32.) An address of 187 Bentley Place, Port Townsend has been assigned to the parcel.
Bentley Place is private (P613).
33.) The parcel is served by the Moa-Tel water system.
34.) The parcel was created through the Lundstrom's Addition to Junction City on January 31,
1890. No AFN.
35.) A septic permit (SEP07-0006)was finaled on September 11, 2007. An address
(ADR10-0024)was finaled.
36.) THE PROJECT IS SUBJECT TO COMPLIANCE WITH THE DEPARTMENT OF
ECOLOGY IN STREAM FLOW RULE OF WRIA 17. THE PARCEL IS LOCATED
WITHIN THE Snow SUBBASIN IN A DESIGNATED RESERVE MANAGEMENT AREA;
AS SUCH, CONSERVATION STANDARDS APPLY AS FOLLOWS:
1. A PERMIT-EXEMPT WELL SERVING AN INDIVIDUAL USER SHALL NOT EXCEED
A MAXIMUM OF 500 GALLONS PER DAY(GPD) OR AN ANNUAL AVERAGE MORE
THAN 350 GPD, FOR ALL PERMIT-EXEMPT USES AUTHORIZED UNDER RCW
90.44.050. (WAC 173-517-120(1)(B))
2. A WELL SERVING A GROUP DOMESTIC SYSTEM SHALL NOT EXCEED A
MAXIMUM USE OF 500 GALLONS PER DAY(GPD) OR AN ANNUAL AVERAGE MORE
THAN 350 GPD, FOR EACH RESIDENCE, AND SHALL NOT EXCEED A TOTAL USE
OF 5,000 GPD FOR THE GROUP. THE DESIGN AND CONSTRUCTION OF GROUP
DOMESTIC SYSTEMS MUST BE CONSISTENT WITH APPLICABLE STATE
DEPARTMENT OF HEALTH REQUIREMENTS AND APPLICABLE JEFFERSON
COUNTY OR CLALLAM COUNTY REQUIREMENTS. (WAC 173-517-120(1)(C))
INSTALLATION OF A WATER METER, MEETING DEPARTMENT OF ECOLOGY
SPECIFICATIONS, IS REQUIRED FOR ALL NEW USES THROUGHOUT THE
WATERSHED. (WAC 173-517-180). BROCHURES WITH SPECIFICATIONS ARE
ENCLOSED WITH THE PERMIT.
REFER TO ENCLOSED DOCUMENTS FOR MORE INFORMATION OR CONTACT
ECOLOGY AT 360-407-6300.
37.) On August 24, 2010, the Administrator approved a reduced setback to the adjacent
commercial forest lands to the immediate east to a minimum of 70 feet. The building
setback shall be no less than 70 feet to the eastern property line. (See applicants letter
dated 8/18/10 in MLA file).
38.) NOTICE: This permit does nccuse the proponent from complying withIIIt
r local,
state, and federal ordinances, regulations, or statutes applicable to the propc,,ed
development, but consistent with RCW 90.58.
Development pursuant to this permit shall be undertaken subject to the applicable policies
and performance standards of the Jefferson County Shoreline Management Master
Program and the Jefferson County Unified Development Code.
If during excavation or development of the site an area of potential archaeological
significance is uncovered, all activity in the immediate area shall be halted, and the
Administrator shall be notified at once.
The Federal Endangered Species Act rules to protect threatened Chinook and
Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been
listed as threatened since early 2000. Under the ESA, any person may bring lawsuit
against any individual or agency that"takes" listed species (defined as causing harm,
harassing, or damaging habitat for the listed species). In addition, the National Marine
Fisheries Service can levy penalties. All areas in Jefferson County are included as
"critical habitat"for a listed species. Development of property along any marine shoreline,
freshwater shoreline, or floodplains could harm habitat if protective measures are not
taken. To minimize the potential to damage habitat, all property owners developing
adjacent to marine shoreline, freshwater shoreline, or floodplains are advised to do the
following:
-All development activities should avoid unstable slopes, wetlands, and forested areas
near surface waters
- Remove minimal vegetation for site development, especially large trees
-Allow trees that have fallen into surface waters to remain there
- Infiltrate stormwater from buildings and driveways onsite through drywells rather than
discharging directly into surface waters or roadside ditches
Any individual, group, or agency can bring suit for a listed species "taking", even if you are
in compliance with Jefferson County development codes. The risk of a lawsuit against
you can be reduced by consulting with a professional fisheries habitat biologist, and
following the recommendations for site development provided by the biologist. For more
information, contact the National Marine Fisheries Service in Seattle, or the U.S. Fish and
Wildlife Service.
01/19/2010 10:49 36037940 JEFF CO PERMIT ER PAGE 01/01
.TACK WESTERMAN III
Jcifrrnnn ('.onnt.Cnnrtl,nnxc
ASSiESSOR Po on. 1220. Part Tow:wad.UI'A 98308
(300):185•9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: ('t x:J `s
ADDRESS: Pt. /)O ( (,, /f r //,d cI(' L()/) 9e)1. ci
PRONE NO. >G t`-' >C 1 <'; -7 7
The purpose of this questionnaire is to obtain information regarding either the
current ineation of a mobile home or the previous ownnership 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.
I)MOIULK" ROME DATA:
(A1 MAKE A 41'Si r 14-7✓tt j _ (II;)MODEL (c)YEAf 2(."[ V
(D) LiENCTII (E) WIDTH ' . (F) SERIAL# 2 A 3 �7
(G) YOt1f PURCHASE PRICE (Do not inelndc sales tax)/ 854; GO PURCHASE DATE g1/q/J0
20 PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE
ADDRESS
4n) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yeas No
Tf Vet. Previons address of mobile.
If No, U1iat County was Mobile assessed in lest year.
3)'WITFHE MOBILE DOME IS TO IiE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE ROME PARK? Yes (No
(II)I1F LOCATED IN MOBILE HOME PARK:
NAME &AI)DItESS OF PARK Lot/Spate #
(C) IF NOT LOCATED IN MOiIH,LE HOME PARK:
NAME OF LAND OWNER: (����-y"r�5 , //ginsr
LOCATION ADDRESS /1l!r/ /5E:,u J i y J/tte, 1 d I`ver lc;Uc;,r-1�
(HEAL PROPERTY PARCEL #/DESCRIPTION 6 G'(71.1?
dilLy
nature b pplieant /)
THANK YOU FOR YOUR HELP! tJ
unmake Kivoiel. Property Technician
03/24/2010 12: 21 3604791050 BUVRITE HOMES PAGE 03/03
• •
m
m
•
CEO i �`-'
ilimi 111 11, 6!' I t-`-' vz fL"'.•.ft
1Ji ��
.1
r— -- — •— -- -- — --._ 14z39V� N.,
0
V I 11,0 .,,ill 1
Illame. §'Z 1 � !
I/Il rnr� '-" lulL.1 !
- 0_ 1 1 ,
i ,,al...Firinviral N.\
111 $ c.dig f •
1 ■-c; 'keg I iJ .
Milli- il
a 1 r I Refer igi I
�'1 c f
I O - =Y o
1
C� in s l I f..r
_,Iliti
I ' E i,c.L. LD
_.c Raind Brit
gr
i iti
iolit
� qii1
•
� rng ' ' I ----Ir�3 • !`
•
•
co
t..` J
v,
co
a Cy cn•� f r 1 �)
T o I I -a 1 *.
I
1
I 1 _,
1 I
1,..._SC) 0 ----'IC".
C1 •
t fri
E C)
00
3 „ _ ,7_._
N 0
d
40 Zcr O '5 O
!A m N ) 7
Z° ° . ] CN - _, ,.
I d
J — GQ ¢ (di tQ G� / V 5 d
111
'Fl —
9,4' . . • : CN
I E' :I A....,.;,_,
7r
iiir .
p �
1 . .
t v)I * . 'L, ' C
......dg CI'
i 0
4 P �
'''Ki* . 'C'll cr,
. fix_ 03
\\ •
. - —Th
04
i X \ _ . •
'` \
°y
_ A
. q ..,....
_ ± ,„.,
_ „., c.,..,\___
. .
\ II
II _ Ak... ,.;—, cz,
Lq LC) __J-----___-- ' —r\-1 I • ti
II
) / to k
. , \'. t.t Z 4
A�� 0N co& JEFFERSODUNTY
111
W ` -, j DEPARTMENT OF COMMUNITY DEVELOPMENT
`' '"4 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
.q�, G�p� www.co.jefferson.wa.us/commdevelopment
81N
Master Permit Application MLA: 10l — a-T5
Project Description(include separate sheets as necessary):
. /`--"V •7/i///N / /t /1 /AJ .t `ez i'e-ci 2//oliiz-
Tax Parcel Property
Number: 14 7 z 6) l 0 / Size: 63.oc,c „f t- (acres/square feet)
Site Address and/or Directions to Property: "
J7C Ai 1cy }'k( e c /c Y i
/S ,,,,,"/c'G✓ (l-F
.c1:,,�, c. Li�(/l'rI5 ,e,",,,,,,,, ,,/)
Property Owner(s)of Record: �l i/f 7i S . (_--//icy 7-7--
Telephone: -; 'c')-:>C`( I• I','-/ ,) Fax: email:
Mailing Address: i:)(?. /7(X film/ 1&k r ,2/,cd/tl c, /[,z7 9 s 1
Applicant/Agent(if different from owner):/�j � t;-, i i-e-2/ivi Wp cjiic-1, I/ yj/J0,t Al
Telephone: rjlo0-6,Rj--077 - Fax: .160-6 (-67 6 email:�ir ,ia La,-t, i el arj<cs.Ca
,77
Mailing Address: 2 c:;q f7C-5,, /J.�9 1), . z1 /{y1 /.1;19 1,4=�8 ',
What kind of Permit?(Check each box that applies
Building 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]*"
❑ Single Family ❑Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
A:Manufactured Home 0 Modular ❑ Special Use(Essential Public Facilities)**
❑ Commercial* ❑ Boundary Line Adjustment
❑ Change of Use ❑ Short Plat**
❑ Address ❑ Road Approach 0 Binding Site Plan**
❑ Home Business ❑ Cottagelndustry ❑ Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign ❑ Plat Vacation/Alteration**
0 Allowed"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
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium ❑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 1}21 A/it? /6v. L t 4 ir'k' , to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE U Zi/l� : `` , i / �"
Z� t Date: -D/ -2 10
/
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 • •vide access -- right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
revi- ;•• any,_�uired later i p=.tions. Staffs ac -ss and right of entry will be assumed unless the applicant informs the County in writing at the
ti e of the •pr"•-tion th t,h- or/e/ants prior no ce.
,; Si.natur-. `i fir,;dd2"�� „ Date: C /6
The action or actions Appli . t will underta je a result of the issuance eof 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 s been issu will not vi a the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)e en if o are in co li ce with the Jeffers County development code.The Applicant acknowledges that he,she or it holds individual
and non-r nsf ' re po ibi' for herig to a complying with the ESA. The Applicant has read this disclaimer a signs nd dates it below.
Signature 4 Date: .33 ///6
�
\Documents and Settings\carat\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.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 ss ing the resp nsibility of the eneral Contractor for the proposed project.
_ r
Signature: - % .< ;, Date:
GENERAL CO�t TRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAx:
hi v,d,ci (Jli'6') (�•�')
MAILING ADDRESS: �,c �� �// pp ,! ,?EMAIL: �)irdiGt b y-fi ie-ihotiic'S_, cot,,'7
��r'��L.S N�' � %0 / �'1C��tii�) f�';t, �,
CONTRACTOR'S LICENSE WAINS
NUMBER: iiii
7�/Af/� OS 4/O NUMBER ic. 7/A)36 2
ARCHITECT/ENGINEER: F i i PHONE ( ) FAx:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
N(New X Wood Existing: ❑ Sewer
❑ Addition IJ Steel Proposed: ;- Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: z Height: Individual Syste
❑ Repair ❑ Masonry SEP Permit# 0 Ct`
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: U Private well ❑ Two Party
Type of Heat: Proposed: -3 ❑ Public
Total: 3 Name of System:/i/Li-i c /
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 0 Above ground Tank Size of Propane Tank:
❑Heat Stove ❑Cook Stove 0 Woodstove ❑ Fireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review:
`.)'to r---I 5
2nd Floor Heated Consistency Review: 5
Other Heated Base fee:
Mezzanine Additional Section: --
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
''
Garage/Carport SUBTOTAL , �. ��.
Decks 911/Rd Approach fee:
,; - Vx 4/6e.�;��liz f 75.ih
-;2 AN)id(,)L
Other UU TOTAL: $ � -mac j
Receipt Number: I I--7q 7
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: ---Ll�c_�
.Fair market value of all labor and materials foundation to finish _// L1
Initials: / —.2
C:\Documents and Settings\caral\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc