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HomeMy WebLinkAboutBLD2010-00323 • • CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 Carl Smith, Director/Building Official PERMIT #: BLD10-00323 SITE ADDRESS: 762 MOUNTAIN TRAIL RD Issue Date: 11/9/2010 BRINNON, 98320 Final Date: 7/9/2012 APPLICANT: TONYA SHRUM PHONE: 503-292-7501 NORMA BRIDGES 8400 SW FAIRWAY DR PORTLAND OR 97225-2758 SUBDIVISION: OLYMPIC CANAL ADDITION 7 Block: 14 Lot: 66 PARCEL NUMBER: 981901406 Section: 16 Township: 25 N Range: 02 W PROJECT DESCRIPTION: M/H REPLACEMENT - SER#17740 THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2009 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes (no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 7/9/2012 \\tidemark\data\forms\F_BLD_Occupancy.rpt 7/30/2012 ! ! II To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection. 1. 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 Erosion Control MH Foundation Blocking&Tie Down Skirting&Ventilation Gas Line: Exterior Propane Tank Pressure Test Drywell/Alt Drainage Address Posted Miscellaneous n, PRIOR TO FINAL BUILDING INSPECTION, PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN ORIGINAL "FINISHED' CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT CO 3 HAS BEEN VERIFIED BY A LAND SURVEYOR, ENGINEER, OR ARCHITECT AUTHORIZED BY LAW TO CERTIFY ELEVATION INFORMATION IN THE STATE OF WASHINGTON. FINAL INSPECTION 1±c2 FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR SPECIAL CONDITIONS APPLY-SEE REVERSE MLA10-00339 •UILDING PERMIT APPLICAON Review Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD10-00323 Received Date: 9/7/2010 SITE ADDRESS: 762 MOUNTAIN TRAIL RD BRINNON, 98320 OWNER: TONYA SHRUM PHONE: 503-292-7501 NORMA BRIDGES 8445 SW BRENTWOOD ST PORTLAND OR 972252721 OLYMPIC CANAL ADDITION 7 SUBDIVISION: Block: 14 Lot: 66 PARCEL NUMBER: 981901406 Section: 16 Township: 25 N Range: 02 W CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2011 REPRESENTATIVE: JAIME KOZELISKY PHONE: (360) 385-3215 1112 S JACOB MILLER RD (360) 385-3215 PORT TOWNSEND WA 98368 PROJECT DESCRIPTION M/H REPLACEMENT TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 840 VALUATION CODE EDITION: 2009 ADD'L: HEAT TYPE: EEE OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 ( uting Date: Type Amount Paid By: sate: Receipt: APPROVED Manufactured Homes $213.00 LYK 09/07/10 120038 State Building Code $4.50 LYK 09/07/10 120038 NOV 9 2010 Potable Water Application $98.00 LYK 09/07/10 120038 Total: $315.50 Jefferson County Planning & Building Department • . SPECIAL CONDITIONS CASE # BLD10-00323 1.) See SPAAD ZON09-00011 for findings that apply to this property and project. 2.) See SPAAD ZON09-00011 for conditions that apply to this property and are adopted for BLD10-00323. 3.) A"Construction Drawing" Flood Elevation Certificate was prepared by a licensed surveyor and submitted with the application. The Certificate identified the base flood elevation of 17.5 feet. The lowest floor of the structure is required to be elevated at least one (1) foot above base flood elevation. PRIOR TO FINAL BUILDING INSPECTION, PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN ORIGINAL "FINISHED" CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT HAS BEEN VERIFIED BY A LAND SURVEYOR, ENGINEER, OR ARCHITECT AUTHORIZED BY LAW TO CERTIFY ELEVATION INFORMATION IN THE STATE OF WASHINGTON. 4.) Flood hazard reduction measures are to be used as required by the Jefferson County Flood Damage Prevention Ordinance 07-0515-06 (Jefferson County Code Chapter 15.15). 5.) The project shall adhere to the Best Management Practices (BMPs) 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. 6.) The applicant is proposing to create or add 2,500 square feet of impervious surface and 1,800 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. 7.) A Stormwater 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 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. 8.) The site plan as submitted with the Builiding Permit application on September 7, 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 5, 2010 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 9.) This approval is for a Manufactured Home Replacement 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. 10.) A Declaration of Restrictive Covenant has been recorded on January 26, 2007 under AFN 519859 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. 11.) 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. 12.) This parcel is within a no shooting area per JCC 8.50. 13.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 14.) Minimum setback from Mountain Trail Road right-of-way shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum setback from Duckabush River shall be landward of the Meander line as identified on the face of the recorded plat. 15.) 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 Count urUwuse ASSESSOR I'O fox 1220. Port Townsend, OVA 98368 (360) 385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDIt SS: NAME: r'/ c_ I S� 6-i,2 / l9/'1 :�12 t'��f ADDRESS: -2-- /U r;al e'��4'Z _ fiI--� R��� PHONE NO. �03-- 292 — 73-0 / >/i r- 9/3oD e400 .ski) ray /.v c6i-i ye Ar//a // Die 97 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. 10MOBILE HOME DATA: (Al MAKE P0,4 ` (B) MODEL �`��e K. (C) YEAR / < --' 0 / (D) LENGTH (E) WIDTH ��' (F) SERIAL # I 7 7 T- (G) YOUR PURCHASE PRICE (Do not include sales tat 7/ 5(961 PURCHASE DATE/0/09 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE,, TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE / l7 +fir/ dq - -S ADDRESS 20/ 6 ,d., 'J r 1)e S0 LC/� f'2J/(J ! 9e3e a (B) WAS }MOBILE HOME ASSESSED IN,JEF,FERSON COUNTY LAST YEAR?Yes `_h cue-- MAC/s r-Gi e i/ /i4 .she er) i�'t �Eet:A.,C, If No, What County was Mobile assessed in last year. �i/c?' if aA-( Z L‘‘..z. y 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes 161t...7 (B)IF LOCATED IN MOBILE HOME PARK: NAME tt ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: ----/ - / , �/ NAME OF LAND OWNER: l 0.1yQ ''` ru"z" l LOCATION ADDRESS 76 2 Daptiebk /,----,;/ / -C, S6 /iifro k'/�f 1� REAL PROPERTY PARCEL #/DESCRIPTION 9.0-/?0,46 t e l e//g2/4v7 ...... ------7____ 11 Signature of applicant THANK YOU FOR YOUR HELP! Lauralee Kiesel. Property Technician N 4. 1 O O X rx 0 N W m -CI IiM ■ JJ_I JJ A 1 •• JJJ aJ I 4 bil I IIIIM ®k m 0_I O � 0 x I Z 'co I > I J N ;JJJJ ;Jill ,Jill I8 /J_ZJ J 0 /J J_=J z ,JJ_,YJJ 2 ,Jl_ J a ,JJJJJ juJJJJ O s JJJJJJ r_ 1 I 2131311 I 1 1 /13"s R: ig mm - .J :1 1 J . _NJJJ ' ;� 1_. Jjlll `4 1 I( O. �O o1 . 0 N W m x CC s W i- 1 (n O a - L J • 98 i ci o r '-ID'r` �9o1(-1O r. a i --,_60.0' ,t t et t1E • 4.N l -tea Meander Line 1 1 si7-E pi_ Ak 1, 7 70 s4/Z., ; / //30 ' _ ell: N t a 5-4e 4►eu. 2-5 QaOs-( • ,a /iiM; ML409--0oo4g - r5PA/A b ill „ . , : �e N I \\ • I2x 24 • �S'of Mt � ��-��I ; 1�2�os; k` lrr-Tees, Cbto s . . tfue 92.iiall DI) �a -irk. . d. I 110:0 proposed 24oppd.1 O x 40 x ;t�+< ' bottomless Intermittent �'` acid filter �` / ,. / 1i' .11 . 10 DpinMld Protection Zone bendrnerk set by surveyor rlfl 7a0sf `..:.::::.. ', • /0q 41110:smaatler,erle�lase � '.:• ;:fit;,.: il d lit •••.•::,.,:.::,;: z!i::•. -- -Base noon elevram=l7 5 �/ ::' (tYwc=t-.ee detail 4 1 th APPRO TLX i1j 1 :. SITE PLAN rhap. `:L`;: , :::::::fit' ; et±23' �%.�r r ��_ta drat . t.: -. 6 -- :,r r NOV 0 5 2010 12o.o. N DEPT I L PMENT SIG U D311. -_______ 1 __ 1 Jac- Nam Si 2 s Se c,:oit /6irio A:-/' 254/ Ale 2i .. an Xr,,e/q 76 2 /1-4 tom; / RAP, y Farce ! ; Lo-- ,6 b ,f 1-0. 67 8L 14� g - l Ta /0/ 97)/40A 4o7) /�aal i` rgl�a ,,i -7 4 7/ n aC l....L..�> �/ 1 >�i,�.//.s,. .� n/) I ✓ 1' � vvr r i,v i� , I L<---/I/y LV!`t-K-�r.r ///1%N /vi ,c..zc,/v ! % U.B.DEPAa:';yFNT OF HOMELAND SECURI'! ELEVATION CERTIFICATE 0M8 No, 1660-0008 Federal Emergency Management Agency National Flood Insurance Program Expires March 31,2012 Important: Read the instructions on pages 1-9. SECTION A-PROPERTY INFORMATION iiFi9'ta;3yPr ;Al. Building Owners Name -.•, ,.1„„,�,.,, l `:)r -TO N`(;A SIB RVM �I(>}it's leq'�1,�s• t��j�•:«�, uur� ,�,�t..Y, AZ Building Street Address(including Apt„Unit,Suite,and/or Bldg.No)or P.O,Route and Box No. i P je ' `"I h'iM[Lh �81 1 76Z MOuryT I�1 TRtL rscp, toil d�' 1 ki5f5 I 1 {' ,° �r City l(C I�VtJQ1�J State •.•,dr,••1 i h �i l z c t :�rkn ZIP Code Cln-ZO A3. Property Description(Lot aria-Block Numbers,Tax Parcel Number, C� 1-art7 66 67 �SLOi✓yt; 1t-1 OLYIIPYG - to Legal Description,etc.) AIr AND, -4 LPN.v- g B t- 9 0 t- t-I D b A4. Building Use(e.g„Residential,Non-Residential,Addition,Accessory,etc,) l'js� [> AS. Latitude/Longitude:Lat. 431 1&7.f78e Long. 1IV .6' A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain insurance. Horizontal Datum: 0 NAD 1827 NAD 1983 A7. Building Diagram Number 8 flood A8. For a building with a crawlspace or enclosure(s); a) Square footage of crewispace or enclosure(s) 847 For a Square footage with of attached garage; b) No.of permanent flood openings in the crawlspace or fl ba) permanent flood attached openings in WA sq ft enclosure(s)within 1.0 foot above adjacent grade 0 b) No.withino ,0ff above adjacent grin the atta garage c) Total net area of flood openings in A8.b et foot adjacent grade NA, d) TotalEngineered flood openings? si Yes No --�sq In c) Total net area of flood openings In A9.b Nt sq in d) Engineered flood openings? Cl Yes ❑No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION 81.NFIP Community Name&Community Number 82.Count Name 53OO6° .FSFRSaN ! 83.State { t1 N it.i c4 RtTa R l,e-T>rb WA, Bd.Map/Panel Number B5.Suffix 136,FIRM index 67.FIRM Panel 88.Flood B9•Base Flood Elevation(s)(Zone 00bCi (�W Date Effective/Revised Date Zone(s) AO,use base flood depth) 7- 1P%-• 19BZ A_ 1 17, 0' 810. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in item 89. ❑FIS Profile ix FIRM Community Determined ❑Other(Describe) 611. Indicate elevation datum used for BFE in Item B9:'NGVD 1929 ❑NAVE)1986 Other(Describe) 812. is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected _Area(OPA)? 0 Yes No Designation Date ❑CBRS ❑OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. Building elevations are based on; a Construction Drawings. ❑Building Under Construction` *A new Elevation Certificate will be required when construction of the building Is complete. Finished Construction C2. Elevations-Zones Al-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO. Complete Items C2.a-h below according to the building diagram specified in It m A7. Use the same datum as the SEE. Benchmark utilized cNlMA(A1}i c.o.(�-�t, pU1`TP�O 0-R_ Gowv,cs�rtb Benchmark Comments to at ( R-� _c' $- Vertical Datum 1q/k VD fro �60. •Zq' Coi.it/Wr4t. -i-n N6vp II' .9i GOMI E NGKr_ GE- Check the measurement used N GVt , Ni°i) a) Top of bottom floor(including basement,crawlspace,or enclosure floor) 18 _ 1 feet CIb) Top of the next higher floor meters(Puerto Rico only) '2-1 0 feet ❑meters(Puerto Rico only) c) Bottom of the lowest horizontal structural member(V Zones only) WA d) Attached garage(top of slab) ..`❑feet ❑meters(Puerto Rico only) hJ!A .—T❑feet meters(Puerto Rico only) e) Lowest elevation of machinery or equipment servicing the building . } feet(Describe type of equipment and location in Comments) ® ❑meters(Puerto Rico only) t) Lowest adjacent(finished)grade next to building(LAG) (rj ' t- g) Highest adjacent(finished)grade next to building(HAG) •7 feel ❑meters(Puerto Rico only) h) Lowest adjacent grade at lowest elevation of deck or stairs,including I , 3-x feet meters(Puerto Rico only) structural su arty®feet ❑meters(Puerto Rico only) SECTION D-SURVEYOR,ENGINEER,OFt ARCHITECT CERTIFICATION yri This certification is to be signed and sealed by a land surveyor, enortiltect information. I certify that the information on tins Certificate represents my best efforts to interpret by law to avrtify elevation I understand that any false statement may be punishable byR spit t the date lion 100• t S line or imprisonment under f8 tl.S. Code,Section f 001, �,`� GF��;,�St�,� �� 7 Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a c. ///ZE(��� licensed land surveyor? ❑Yes ❑No -_• . r Certifier's NameY //( �i�e� License Number Title /��D S���E�O/2 Company Name �� g� b4 / Addre65 r city /E2(7.- 1 �/?fit .5 -,,C,cfr�- Ns� ' w'f 1 Zl h/ State . /}7] as/ /tG/2� ZIP Code Signature /. DLG� 9 gr ) �/ %G���� / Date Telephone /0(.2- (1 FEMA Form 1-31,Mar09 — . . _ _. ._.. See reverse side for continuation. R 4 IMPORTANT' In these Spaces,Copy a corresponding information from Section A ; Building Street Address(Including Apt.,Unit,Suite,and/or Bldg.No.) P.O.Route and Box ��11 ! i! �c11 TAtf� or P No. 11gg�� 5 City �R N��� State ZIP Code iicld�71114ipf1tl �- 4�(�iil k�„ �itd .:RIC ttbA' i .rr8 it W A CI��Z O la•�_'__ 7,i;' 1 "� ar l I it' yu.(' . Ai; SECTION D-SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED) .Copy both sties of this Elevation Certificate for(1)community official,(2)Insurance agent/company,and(3)building owner, Comments A\ `r MrORW( 1 a-1 1-1ARK, w ., \r, 01.I s, 3i 12.t7,5, Msi'rtiv.-roEw .A Rt1AN9ty i 13S14-tMNRK WA 1--:-. 1- --V of Rea '1,hy1+'E I- tt t vp&T- �pE. o r©W 1�. 10LE °' �d✓I�► PE LIi4E _Ccor OF FOOD=t(3,boitmvp`29 t.S� 4'k sYcfM(.Wc,R Signature Date 0 Check here if SECTION E-BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONEA(WITHOUTtBFE)ents For Zones AO and A(without BFE),complete Items El-E5. If the Certificate is Intended to support a LOMA or LOMR-F requesst,complete Sections A,B, and C. For Items El-E4,use natural grade,if available. Check the measurement used. in Puerto Rico only,enter molars. El. Provide elevation Information for the following and check the appropriate boxes to show whether the elevation Is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG), a)Top of bottom floor(including basement,crewispace,or enclosure)is b)Top of bottom floor(including basement,crawlspace,or enclosure ❑feet ❑meters ❑above or ❑below the HAG. )Is '� [Meet ❑meters ❑above or ❑below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Secti MA items 8 and/or 9(see Rages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is ❑feet L_.1 meters ❑above or U below the HAG, E3. Attached garage(top of Slab)Is . ❑feet Q meters 0 above or D below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is ❑feet 0 meters ❑above or 0 below the HAG. E5. Zone AO only: If no flood depth number is available,Is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? ❑ Yes Ei No 0 Unknown. The local official must certify this information In Section G. SECTION F-PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property Owner or owners authorized representative who completes Sections A.B,and E for Zone A(without a FEMA-issued or community-Issued BFE) or Zone AO must sign here. The statements in Sections A,9,end E are correct to the best of my knowledge, Property Owner's or Owners Authorized Representative's Name Address City State ZIP Code Signature Date Telephone Comments i .utr}> IQ, ) , t VA _Co tNCR ,�r:CAU12Y 51,0614,5'„ i C1 t16Nr PAt? TeDA! h NM Tish_ ❑_ Check here if attachments SECTION G-COMMUNITY INFORMATION(OPTIONAL) The local official who Is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E), end G of this Elevation Certificate. Complete the applicable Item(s)and sign below. Check the measurement used in Items GO and G9. G1. icy ,he information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who YY�� is authorized by taw to certify elevation Information. (Indicate the source and date of the elevation data In the Comments area below.) G2. ❑ A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-Issued BFE)Or Zone AO. 03. X The following information(Items G4•G8)is provided for community floodplain management purposes. G4.Permit Number G5. Date Permit Issued I GB, DatetCerlifleat@Of Complta ce/O apancy Issued GT. This permit has been issued for: ,'New Conyttruction Substan+iar ❑ Impm.bment G8. Elevation of es-bunt lowest floor(Including basement)Of the building 2I 0 .L/feet ❑meters(PR) Datum G9. BFE or(in Zone AO)depth of flooding at the building site Co.:G10 nity's,design fl elevation �`� . 5- ' `-t ❑meters(PR) Datum ❑feet meters(PR) Datum Local Official's Name i le ::r:tYNam3 O� Telephone © — --C �j V Date Comments ❑Check here if attachments FEMA Form 81-31,Mar 09 Replaces all previous editions I, 411 0 Building Photographs See Instructions for Item A6. For Insurance Company Use: Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Box No. Policy Number 762 Moor;lAit l `-FRNiL RP CityZIP Code Company NAIC Number I R\M\J ON State q e- z o If using the Elevation Certificate to obtain NFIP flood insurance, affix at least two building photographs below according to the instructions for Item A6. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." If submitting more photographs than will fit on this page, use the Continuation Page on the reverse. F L. w y.; • :y ti km!'tY', � _. _. - • ar.`,- ,;'" it, R., Alitriiiiia RA vtE� -- 416„ r' w. 44' M 4 , . fi ' AP,, y ,. 11 a4 f Laii ,t i./ I 41..'1•..L4 ' s R.• .� tip! ....... ..- rkoN VI \rv' .---/` • BUILDER STATEMENT • The signer of this st ement does hereby certify(that hey are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assu . g the responsibility of the a al Contractor for the proposed project. Signature: ' Date: L"i— Z S —/ GENERAL CONTRACTOR MANUFACTURED HOME INSTALLER: PHONE: Fax: o Z.e %/S k y 1/0 $ ir'- i�.. a)3 S 32-Ls (g6v 3e.--32Ls MAILING ADDRESS: 5-.3 Al, G ,�t�P f r-/- T, tfe EMAIL: �pg/k7C: ?a` L��/K CONTRACTOR'S LICENSE ,/ ( WAINS j/ r D L.,1 f-^1; NUMBER: t OZE-L H_c 0 rL-7C-3 NUMBER /` L V ��V/.':I v ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ►'��New 0 Wood Existing: .4/ 0 Sewer ❑ Addition ❑ Steel Proposed: Bank 0 Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: 0 Individual SystemM O Repair ❑ Masonry SEP Permit# ('n ro — ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: ❑ Public E ic=f i Total: 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 I' 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 FiorOffice Use:Onlyfft. m..,Ot -Amount ° Revision,t ; Main Floor Heated , EH BId App Review: Floor Heated r Consistency Review: C9)3 — Other Heated Base fee: t Mezzanine 4 Yin �1C1� Heated Basement Plan Check fe� Unheated Basement State Surcharge fee: /' Other Unheated Pot Water Review fee: `` 1` Garage/Carport SUBTOTAL ' Decks ' 911/Rd Approach fee: Cy 1 3 Other a TOTAL: $ 1 I3(40 Receipt Number: ., -'• F Cash/Check Number: (�q sis' ::,„,_:: „.,:,,,, ESTIMATED COST(REQUIRED) Date: b� *Fair market value of all labor and materials foundation to finish `•'�✓ Initial • ' G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc rilik2A 4`S0N cQ� JEFFERSON •uNTY • DEPARTMENT OF COMMUNITY DEVELOPMENT4\. 621 Sheridan Street• Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax 4�' p' www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: to l3, 09 P ject Description (include separate eets as necessary): Qrapi Tax Parcel Number: 98/9 1 TVO < �r yDI�-07 Property jSize: / (acres/square feet) Site Address and/or Directions to Property: -7 -2 Mc4.0i 4,`,/._ t%wtt{ rd 6r1126104( wA Property Owner(s)of Record: L�nyY Al.,,,,74 Telephone: 503— 272—7si) / F x: /email: Mailing Address: f�0 l �l�t (a r 9722$' Applicant/Agent(if different from owner): 1^1 L $ L4r►1 Ofr .1g,i-t-e-- A27 -d0/ism" Telephone: 5 3— 797-36'04� / Fax:l�" mail: SCA-a�� cPSSGO,uS Mailing Address: 2 — (,4^-zb l V'G ' " r4 4`2e 0 What kind of Permit?(Check each box that applies OifBuilding 0 Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor,Major or Reasonable Economic Use) ❑Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a),C(d),or C]** 0 Manufactured Home 0 Modular ❑ Discretionary"D"or Unnamed Use Classification ❑ Commercial* 0 Special Use(Essential Public Facilities)** ❑ Change of Use ❑ Boundary Line Adjustment ❑ Address ❑ Road Approach 0 Short Plat** i ❑ Home Business 0 Cottage Industry 0 Binding Site Plan** 0 LongPlat** ❑Sign Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration** 0 Stormwater Management Cl Shoreline Master Program Exemption/Permit Revisions** ❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development** ❑Temporary Use ❑Shoreline Management Variance ❑Wireless Telecommunication* 0 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: �r2•� J ,I 2 DESIGNATION OF AGENT Oh \it<f 71t-€. /c ; e/ilk y I hereby designate to act as my agent in matters relating to this application for permit(§). OWNER SIGNATURE or 4.i' "v Date: Z By signing this application form,the .lner/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 pro ide access and right of ent o Jefferson County and its employees,representatives or agents for the sole purpose of application review and any req red later inspections. Staff' ss and right of entry will be assumed unless the applicant informs the County in writing at the time of th appf on that he or she wants prior n ti 7 —7/ 7 `Signature: 1 Date: - JO The action or actions Appl c nt 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 iss ed will not violate the ES;. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if yo are in compliance with th il Je rson County development code.The Applicant acknowledges that he,she or it holds individual and non- ansfe le responsibility for adhenn sand complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: aL1E l ' 'tea... Date: - Z:-in i G:\PemtitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc