HomeMy WebLinkAboutBLD2010-00276 MLA10-00298
�UILDING PERMIT APPLIC ON Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #:
SITE ADDRESS: BLD10-00276
THORNDYKE RD Received Date: 8/2/2010
OWNER: DANIEL A IVERSON TRUSTEE PHONE:
JEAN E IVERSON TRUSTEE
144 RAINBOW DR#4460
LIVINGSTON TX 77399-1044 TRAILS END HOMESITES
SUBDIVISION: Block: 3 Lot: 21
PARCEL NUMBER: 950100320 Section: 16 Township: 27 N Range: 01 E
CONTRACTOR: SOUTH SHORE CONSTRUCTION PHONE: (360) 275-0818
230 E HILLSIDE DR
BELFAIR WA 98528
Contractor's License SOUTHSC016NL Expires 3/13/2012
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 1,680
CODE EDITION: 2009 ADD'L: HEAT TYPE: EEE
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: BRIDGEHVN
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 3
Total: 2 tel:
Routing Date:
Type au Bv: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 08/02/10 119865OVE
Potable Water Application $98.00 LYK 08/02/10 1198651
Total: $311.00 NOV 2010
Jefferson County Planning
& Building Department
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 Minimum setback from Thorndyke Road right-of-way shall be 20 feet.
Minimum north and south property line setbacks shall be 5 feet.
Minimum setback from top of landslide hazard area bank shall be 20
feet.
Setbacks
Erosion Control
Erosion Control SEE CONDITION 3
MH Foundation I /d .,
Blocking&Tie Down / �.
Skirting&Ventilation
Gas Line: Exterior
Propane Tank
Pressure Test
Drywell/Alt Drainage
Drywell/Alt Drainage SEE CONDITION I &2 - SWT&GEOTECH CERTIFICATION
PRIOR TO FINAL
Exterior Lighting
Address Posted
& Cot ►+ 2 I-ter tzp -f-v1a..Q.
FINAL INSPECTION 2"l r Fn
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY-SEE REVERSE
•
SPECIAL CONDITIONS CASE # BLD10-00276
1.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT AN
ORIGINAL WRITTEN WET-STAMPED LETTER FROM ENVIROTECH ENGINEERING
- STATING THAT THE STORMWATER FACILITY HAS BEEN CONSTRUCTED IN
ACCORDANCE WITH THE REQUIREMENTS OF THE "DRAINAGE FACILITY" LETTER
DATED oCTOBER 20, 1010 AS SIGNED BY MICHAEL STRATON, P.E. OF
ENVIROTECH ENGINEERING.
2.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT AN
ORIGINAL WRITTEN LETTER FROM ENVIROTECH ENGINEERING WHO PREPARED
/THE GEOTECHNICAL REPORT DATED JULY 21, 2010 STATING THAT THE
• STRUCTURE AND/OR FACILITIES HAVE BEEN CONSTRUCTED IN CONFORMANCE
WITH THE REQUIREMENTS OF THE "GEOTECHNICAL REPORT." THE LETTER
SHALL BE WET-STAMPED BY THE LICENSED GEOLOGIST/ENGINEER.
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.) Water line must maintain 10' min. setback from any portion of the septic system.
5.) The application was reviewed by the Jefferson County Department of Community
Development staff on October 25, 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:
SUSC aquifer recharge area; high risk SIPZ.
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 rural portions of Jefferson County.
7.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
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.) Marine shorelines and islan.e susceptible to a condition that is knowrillseawater
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.
10.) The parcel is located within a High Risk SIPZ (seawater intrusion protection zone)
according to the County GIS map. There are 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 High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a
history of chloride analyses above 200 milligrams per liter(mg/L).
11.) 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.
12.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
13.) A vegetative buffer of 20-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.) A Geotechnical Report dated July 21, 2010 prepared by Envirotech Engineering was
submitted in conjunction with this application. The report addressed the stability of the
geologic hazard area. A setback of 20-feet shall be measured perpendicularly from the
top or toe of the geologic hazard to the proposed development.
15.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated.
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.
16.) 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."
17.) All construction activities shall not encroach upon the landslide hazard area buffer. This
includes the storage or preparation of materials.
18.) 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.
19.) 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.
20.) The applicant is proposing to create or add 2256 square feet of impervious surface and
3906 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.
21.) A Stormwater Site Plan has ill submitted and approved by the Depart of
Community Development. Once the subject permit has been issued the app icant 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.
22.) 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).
23.) The revised site dated October 20, 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 November 3, 2010 shall be resubmitted for review and approval by
Jefferson County Department of Community Development.
24.) This approval is for a manufactured home and garage attached to the 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.
25.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
26.) A Declaration of Restrictive Covenant has been recorded on September 14, 2010 under
AFN 554194 for the purpose of consolidating the lots to meet minimum land area
requirements for on-site septic ad to allow zero lot line setbacks. The Covenant is strictly
for building and septic purposes only.
27.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
28.) 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.
29.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
30.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc. Pre-existing legal
lots of record less than one acre in size in rural residential districts are subject to the
stormwater requirements in Chapter 18.30 JCC and must meet the"Area of Impervious
Surface Coverage"to the maximum extent practicable as determined by the administrator.
Lot coverage is defined as amount of impervious surface, which includes rooftops,
driveways, concrete, etc.
31.) The building height is not to exceed 35 feet.
32.) Minimum setback from Thorndyke Road right-of-way shall be 20 feet. Minimum north and
south property line setbacks shall be 5 feet. Minimum setback from top of landslide
hazard area bank shall be 20 feet.
33.) 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.
34.) 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.
35.) An address of 1513 Thorndyke Road, Port Ludlow has been assigned to the parcel.
Thorndyke Road is a county minor collector(C418708).
36.) The parcel is served by the Bridgehaven Community Club public water system.
37.) A septic permit(SEP10-0098) was approved on November 2, 2010. A building permit
(BLD10-0277) for an attached garage was approved on November 3, 2010. A road
approch permit was cancelled on October 14, 2010.
38.) NOTICE: This permit does excuse the proponent from complying wither local,
state, and federal ordinances, regulations, or statutes applicable to the proposed
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.
JACK WESTERMAN III • Jefferson Counturtliouse
ASSESSOR PO Box 1220, Port Townsend, WA 98368
(360)385.9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: -bah`el 3ceLn
ADDRESS: 230 E f-1"'IIsioLP. D►%'vex I elcia.i r, W)\ cfg52$
PHONE NO. 3(oO- 50•I -13 4'2
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 jirie (B) MODEL Lo2sfric4, !cf(C)YEAR 20 1 0
(D) LENGTH D (E)WIDTH 2-1 (F)SERIAL #
(G) YOUR PURCHASE PRICE (Do not include sales tax) I$i5ome PURCHASE DATE bf%O9/9Vc
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE be-Tra.t�s C Us-km bus iyi tie
ADDRESS 1 oaoc !Lo S I . £ �1au� l�R c B 74
(B) WAS MOBILE HOME ASSESSED IN JEFFEI(SON VOUNTY`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:
AUG Lu u
(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:
LOCATION ADDRESS
REAL PROPERTY PARCEL #/DESCRIPTION
nature of applicant
THANK YOU FOR YOUR HELP!
Lauralee Kiesel, Property Technician
T 4,
• IDm `O 9�
eIA,vi-rotec14 Ewgbweerwwg
teotechvt.%caL ° Etn.VLrovuivt.evitaL°Dra%wage °Roadway
October 20, 2010
I/C South Shore Construction
Daniel and Jean Iverson
1545 Thorndyke Road
Port Ludlow,Washington 98365 (/
Reference: Small Parcel Stormwater Management Plan for the Property Located on Thorndyke Road
Parcel 950-100-320 and 950-100-321, Port Ludlow,Washington
Dear Mr. and Mrs. Iverson,
Envirotech Engineering has previously completed a geotechnical report, and the enclosed small parcel
stormwater management plan for the referenced property.
The drainage design was based on the 2005 Department of Ecology Stormwater Manual for downspout
infiltration systems. Based on the proposed 2,256 sf of roof area, 135 sf of available infiltration area, and
on-site fine and medium sands, drain rock depth should be at least 3 feet in depth. This conclusion was
interpolated from a standard trench width of 2 feet,and a trench length between 30 If(medium sands)and
75 if(fine sands)for every 1000 sf of roof area.
Per the geotechnical report, downspout runoff should not be located within 30 feet of the critical slope.
Although an overflow system at the roof downspout may be located on the west side of the residence,
overflow is not permitted on the east side of the structure. Therefore, it is recommended to utilize an
overflow pipe at the infiltration pit.
We conclude that the drainage design is acceptable with relation to the geotechnical report, prepared by
Envirotech Engineering on July 21, 2010.
Envirotech appreciates the opportunity to be of assistance on this project. We anticipate that this small
parcel stormwater management plan meets your expectations. Please contact Michael Staten at 360-275-
9374 if you have any questions or require additional information.
Sincerely,
Envirotech Engineering
CLYDE
PAL
4`Gov WA Sykv,ST-1)
I /O/2D//O
PG>, ,tb'PGS Rep `��<v APPROVED
SSioNnLY`4G STORM WATER PLAN
Michael Staten, P.E.
Project Director
NOV - 3 2010
74 NE Hurd Road
Tel.-c r, vvashEtn.etovu 98522
JEFFERSi OU aft 3oo-275-9374
DEPT.OF CI E E. EN ceLL: 3wo- 89-6045
SIGNATU• . I1 A !de.4. -II : 300.. fax 2�.5-489
.• • ev&vi.rotech@UeotechvucaLi,A,fo.com
4'
OVERFLOW PIPE AT
INFILTRATION AREA
PREFERRED OVER
DOWNSPOUT OVERFLOW
HODS\
F DRAIN
` ,
:.. ERFLOW SOLID
LID GROUND
SPLASH BLOCK SURFACE
BACKFILL 4' DIA. MIN
PERFORATED PVC
PIPE
2Y. MIN ENCOMPASS rah i
2% MIN DRAINROCK WITH :,yam.:` .,`'yc„`-
�J FILTER FABRIC •-.dip- : ,�,:: 6' MIN
4IPTAi1 .�.=I:`I }
4' DIA. MI .��-Y�.•_AP
SOLID PVC FINE MESH :1�'�� �:�,GT,,,,,,
SCREEN 4' DIA. MIN 'L
CATCH BASIN 3/4' - 1 1/2' •�•�•�•ea,
SUMP SOLID PVC WASHED DRAIN~oy:1 'C► �,
ROCK ".�.�..�..�
L• L• ��� 3' MIN
.�.�..a..�..�
15 FT MIN - �� �• 2•5�
Taketileiireitee
Y....,.....,. 411P`,,r,�f f
ROOF DRAINAGE DETAILS
N.T.S. I ...-1INFILTRATION
SURFACE AREA
TO BE 135 SF
VA'CLYO .
NOTES. `�� �� A ',IA
1. INFILTRATION AREA TO BE LOCATED ON THE SOUTHWEST CORNER OF ,* r r, ,,i,,,,, ,
,
PROPERTY, AS SHOWN ON THE SITE PLAN. /• �� ,/ �4
2. DRAINAGE SYSTEM FOR ROOF RUNOFF SHALL BE INSPECTED BY HOME ' '/
OWNER BI-ANNUALLY, AND MAINTAINED AS NECESSARY. O 4y y'. � O/��/0
�CsIONAC.NG`}
'S
APPROVED
STORM WATER PLAN 1
PROJECT/ OWNER/ LOCATION,
SMALL PARCEL STORMWATER
NOV - 3 2010 MANAGEMENT PLAN
IVERSON
THORNDYKE ROAD
PARCEL 950-100-320 & 950-100-321
JEFFERS OU PORT LUDLOW, WASHINGTON
DEPT.OFAVA. MEN ENGINEER.
)
ENVIROTECH ENGINEERING
SIGNATUR 4' 74 NE HURD ROAD
BELFAIR, WASHINGTON 98528
360-275-9374
DRAINAGE DETAILS
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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 the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALL R: PHONE: FAX:
Berl SY1oYY Q r�S`VVLAC'1tf\ 1 hC. (3ba) S09-134-2 (3 W 2715-(02Sto
MAILING ADDRESS: 230 E E. H i'(side D i ve- EMAIL: ---
CONTRACTOR'S LICENSE e'R �4 r WR 9$523 WAINS
' p
NUMBER: V� 1 '�OL('r-t- SC 1(l I(0 I- NUMBER '3 O
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Fame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
IL-flew Pf Wood Existing: ig ❑ Sewer
❑ Addition ❑ Steel Proposed: 3 Bank 0 Community System
❑ Alteration/Remodel ❑ Concrete Total: 3 Height: CI1-Individual Syste
O Repair ❑ Masonry SEP Permit# IV''q$
❑ Demolition 0 Other: Bedrooms: Water Supply:
PP y:
Existing: .6r. Setback: i I Private well O Two Party
Type of Heat: ff Proposed: public
o{Yic. �►-ced > +r Total: '1- Naing of SSystem:
Bi-i d eWaven
If this is a Commercial Project you must answer the following: ld�
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 1 Above ground Tank Size of Propane Tank:
i Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 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 FoetWR i)se�( niy L Amount e,O;fevision
Main Floor Heated 1(0n O �� EH Bid App Review: r73i
2na Floor Heated ',1;t Consistency Review:
Other Heated T Base fee:
Mezzanine :if.-: t C9 15
:. Additional Section:
Heated Basement Plan Check fee:
Unheated Basement AUGState Surcharge fee: ?
Other Unheated Pot Water Review fee: I ---
Garage/Carport SUBTOTAL
-
Decks - 911/Rd Approach fee: 15 _
Other
TOTAL: $ 5 Li S
1
,,;,, Receipt Number: I l xl����
—
njr 1
' Cash/Check Number: ^Z3�
ESTIMATED COST(REQUIRED) Date: VO
.Fair market value of all labor and materials foundation to finish
Initials: '
G:\PcmvtCentcr\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
•
MaT;t rOCI lAYed 1-1 bme
(7' CO6. JEFFERSON COUNTY
` DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
Q'� Na,�p$ www.co.jefferson.wa.us/commdevelopment\ St ''�(�
Master Permit Application MLA: 1 d O("Ig
Project Description(include separate sheets as necessary):
lien-Va11 Manicac4-c,,red Nome
Tax Parcel Number: (-]50 10 0?j L 0 /q 5 016 0 3 Z I Property Size: (acres/square feet)
Site Address and/or Directions to Property:
Thor n Kv R.oaa1,) b+ Luc low N A 9(g 3(0 s
Property Owner(s)df-t7ecord:"-"De2 K I c-I S' 3ca Ill -a-V e CS a C1
Telephone: C�o - SO el - 13 4-2--- Fax: — email:
Mailing Address: Z30 E• f-/rllsiol-e-- t ) - e l- el i r- W A- ct•$5 Z$
Applicant/Agent(if different from owner): Suul4V1 Sk6Y42i GDY1S-}1 to c i t)n i I hC -
Telephone: Slob —13 4 2— Fax: ?j(or-2-7S-6 2-5 to email: —Mailing Address: 23O 14 4's'rc{.e- b . ' 13p c-,=Ii r Lt),A- 9 S 2X
hat kind of Permit?(Check each box that applies
Building ❑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]**
Manufactured Home 0 Modular ❑Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)**
❑ Change of Use ❑Boundary Line Adjustment
N-Address t$I Road Approach ❑Short Plat**
0 Home Business 0 Cottage Industry ❑Binding Site Plan**
❑Propane 0 Long Plat'"*
❑Sign 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes'Use Consistency Analysis 0 Plat Vacation/Alteration**
❑Stormwater Management 0 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:
AI DESIGNATION OF AGENT
I hereby designate SDt.c{11 �, t.i Ott pn/ line- to a as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE \ Date: 07-2 8 i 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 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 attomey'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 that he or she wants prior not e.
signature: M SS Date: O2 Joa` I to
The action o tions Applicant will undertake as a result of the issuance of this pennit 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-transf•erablv,responsibility for adhering to an�co-mpllying with the ESA. The Applicant has read this disclairper and�ii ns and dates it below.
Signature: �hbf enjoying
Sst_ Date: O Od I 0
G:\peimitcente FORMS\Master Permit Application 5-29-08.doc
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