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HomeMy WebLinkAboutBLD2011-00037 • • 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 #: BLD11-00037 SITE ADDRESS: 2682 DOSEWALLIPS RD Issue Date: 02/28/2011 BRINNON, 98320 Final Date: 1/31/2012 APPLICANT: LOREN FALK PHONE 360-708-1962 DIANE K FALK 2682 DOSEWALLIPS RD BRINNON WA 98320 SUBDIVISION: KNUDSEN PLAT LARGE LOT Block: Lot: 1 PARCEL NUMBER: 602285001 Section: 28 Township: 26 N Range: 02 W PROJECT DESCRIPTION: NEW M/H SER # 33768 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 ON1/31/2012 I.\F_BLD_Occupancy.rpt 10/29/19 MANUFACri'U HOME INS Jefferson CountyRED/MOBILE Department of CommunityTA tATIO DevelopmentNPERMIT 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD11-00037 Received Date: 2/15/2011 SITE ADDRESS: 2682 DOSEWALLIPS RD Issue Date: 2/28/2011 BRINNON, 98320 APPLICANT: LOREN FALK DIANE K FALK 133 STATE ST #78 WA SUBDIVISION: KNUDSENSEUO PLLATEY LARGE 98284-1503LOT Block: Lot: 1 PARCEL#: 602285001 Section: 28 Township: 26 N Range: 02 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: NEW M/H MAKE: YEAR: SIZE: 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 111 Approval Signature Notes Setbacks il /ri '} Erosion Control / "^e r-%QV p ry r `),J ,•__ s /i T_N � MH Foundation `� t" ~�� t \t ,;t Blocking&Tie Down 125_/f Skirting&Ventilation /-61. Gas Line: Exterior Propane Tank I0 Pressure Test Drywell/Alt Drainage Address Posted %-'2c'I I V . _ n u h MS It-2.., i/ 1-0 kn- FINAL INSPECTION L _3 1_12 FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR SPECIAL CONDITIONS APPLY- SEE REVERSE ILDING PERMIT APPLICAN MLA11-00031ReviewType:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD11-00037 Received Date: 2/15/2011 SITE ADDRESS: 2682 DOSEWALLIPS RD BRINNON, 98320 OWNER: LOREN FALK PHONE: 360-708-1962 DIANE K FALK 133 STATE ST #78 SEDRO WOOLLEY WA 98284-1503 KNUDSEN PLAT LARGE LOT SUBDIVISION: Block: Lot: 1 PARCEL NUMBER: 602285001 Section: 28 Township: 26 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI NEW M/H TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,764 VALUATION ADD'L: HEAT TYPE: EEE CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: OCCUPANCY: UNHEATED: #OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 1PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: APPROVED Manufactured Homes $213.00 LYK 02/15/11 123213 Total: $213.00 FEE B zU1i Jefferson County Planning &Building Department ! r SPECIAL CONDITIONS CASE # BLD11-00037 1.) PRIOR TO SCHEDULING A FINAL BUILDING INSPECTION, THE PROPONENT SHALL SUBMIT A WRITTEN LETTER FROM THE GEOLOGIST WHO PREPARED THE GEOTECHNICAL REPORT AND STORMWATER PLAN STATING THAT THE STRUCTURE AND/OR FACILITIES HAVE BEEN CONSTRUCTED IN CONFORMANCE WITH THE REQUIREMENTS OF THE REPORT AND PLAN. THE LETTER SHALL BE STAMPED AND SIGNED BY THE LICENSED GEOLOGIST/ENGINEER. 2.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT A WRITTEN LETTER FROM STEVEN MORTA, PE STATING THAT THE STORMWATER FACILITY HAS BEEN CONSTRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE GEOTECHNICAL ENGINEERING REPORT. 3.) A SILT FENCE SHALL BE INSTALLED, IF DETERMINED TO BE NEEDED, TO PREVENT SILT FROM FLOWING INTO THE STREAM BUFFER OR THE COUNTY RIGHT-OF-WAY. APPLICANT/CONTRACTOR SHALL BE RESPONSIBLE TO MAKE SURE THAT SILT FENCE IS INSTALLED AND MAINTAINED TO THE DOE STANDARDS. THE MINIMUM HEIGHT OF THE TOP OF SILT FENCE SHALL BE 2 FEET AND THE MAXIMUM HEIGHT SHALL BE 2 1/2 FEET ABOVE THE ORIGINAL GROUND SURFACE. THE SILT FENCE SHALL BE BURIED IN A TRENCH TO A MINIMUM DEPTH OF 5 INCHES BELOW THE GROUND SURFACE. THE TRENCH SHALL BE BACKFILLED AND THE SOIL TAMPED IN PLACE OVER THE BURIED PORTION OF THE SILT FENCE, SUCH THAT NO FLOW CAN PASS BENEATH THE FENCE AND SCOURING CAN NOT OCCUR. ANY DAMAGE TO THE SILT FENCE SHALL BE REPAIRED IMMEDIATELY. SEDIMENT DEPOSITS SHALL EITHER BE REMOVED WHEN THE DEPOSIT REACHES APPROXIMATELY ONE-THIRD THE HEIGHT OF THE SILT FENCE, OR A SECOND SILT FENCE SHALL BE INSTALLED. 4.) 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. 5.) Water lines from well must maintain 10' min. setback from any portion of the septic system. 6.) The application was reviewed Ike Jefferson County Department of Comr ity Development staff on February 28, 2011 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: Shoreline Designation (along the Dosewallips River) - Conservancy, High Risk Channel Migration Zone (along the Dosewallips River), Non-typed stream and a Type Ns stream with greater than or equal to 20% grade, Elk Habitat, Moderate Landslide Hazard Area, Frequently Flooded Area (along Dosewallips River), Erosion Hazard Area, Susceptible Aquifer Recharge Area (SUSC). 7.) A geotechnical report prepared by MET (Morta Engineering and Testing) dated March 29, 2008 was submitted with a detached shop application in 2008 to address geologically hazardous areas and stormwater. 8.) THE APPLICANT SHALL FULLY COMPLY WITH THE RECOMMENDATIONS IN THE FOUND IN THE GEOTECHNICAL REPORT PREPARED BY MET (MORTA ENGINEERING AND TESTING) DATED AUGUST 20, 2007 OR ANY SUBSEQUENT ADDENDUMS. 9.) Based on the following comments from DNR, the administrator determined on August 20, 2008 that buffers will not be applied to the non-typed stream shown 25 ft. north of the proposed shop. The following comments were received in 2006 from Ross Goodwin (DNR) regarding streams on the subject parcel: At the request of a potential buyer I (Ross Goodwin) visited Jefferson County parcel 602285001 located on Dosewallips Road to verify two stream classifications. I visited the site on July 14, 2006. I found that the northern stream, shown on the map as a Type 3 water, does not appear to cross the property at the NW corner as shown. It is also not a Type 3 water. The stream was dry at the time of my visit, and the gradient from the Dosewallips River up slope was in excess of 20%. This stream should be considered a Type 5 water. The southern stream, shown on the map as a Type 5 water, is in more or less the correct location. However the channel hits a flat just east of the Dosewallips Road and the water appears to spread out and there is no obvious defined channel at that point. This channel should be considered a non-Typed water. However any activity on this flat should take into consideration a fair amount of sheet flow associated with snow melt and heavy rain events. 10.) 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. 11.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 12.) 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. 13.) Jefferson County has determined that the use of real property for agriculture and forestry operations is a high priority and favored use in the county. The county will not consider to be a nuisance those inconveniences or discomforts arising from such operations, if such operations are consistent with commonly accepted best management practices in compliance with local, state, and federal laws. If your real property includes or is within five hundred (500) feet of real property designated as Rural Residential 1:10 or 1:20, Rural Industrial, Rural Commercial, Agriculture, or Forestry, you may be subject to inconveniences or discomforts arising from such farming and forestry operations, including but not limited to noise, tree removal, odors, flies, fumes, dust, smoke, the operation of farm and forestry machinery during any 24-hour period, the storage and disposal or manure, and the application of permitted fertilizers and permitted pesticides. One or more of these inconveniences may occur as a result of agricultural and forestry operations which are in conformance with existing laws and regulations. 14.) A Type N Stream (Fish and Wipe Habitat Area) has been identified on thilkject property. The stream will require a setback of 75-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 15.) Stream buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 16.) 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. 17.) 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. 18.) 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." 19.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 20.) 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. 21.) 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. 22.) The identified Fish and Wildlife Habitat Area (Type N Stream) near the north parcel boundary, shall maintain a vegetative buffer setback of 75 feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to the proposed shop building and driveway. 23.) An additional setback of five (5) feet is required from the edge of the buffer area to the proposed shop building. 24.) A permanent physical separation along the boundary of the stream buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 25.) Stream buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer - Do Not Remove or Alter Existing Vegetation." 26.) The applicant is proposing to create or add 2664 square feet of impervious surface and 2543 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. 27.) A Stormwater Site Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 28.) 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). 29.) The site plan as submitted with manufactured home installation applicatilikn February 15, 2011 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 February 28, 2011 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 30.) 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. 31.) The parcel has been designated as RR 1:20 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 32.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 33.) 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. 34.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 35.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 36.) The building height is not to exceed 35 feet. 37.) Setback from Dosewallips Road right-of-way is no less than 20 ft., setback from the private access easement on the east side of the parcel is no less than 20 ft., side and rear setbacks are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more restrictive setback shall apply. 38.) 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. 39.) 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. 40.) An address of 2682 Dosewallips Road, Brinnon has been assigned to the parcel. Dosewallips Road is a county minor collecctor(C250008). 41.) This parcel was created through Knudsen Plat under AFN 423216, recorded May 26, 1999, Volume 1, pages 85-90 with the Jefferson County Auditor's office. 42.) The parcel is served by an individual on-site well. 43.) A road approach permit(RAP06-0185) was finaled on April 9, 2009. A buidling permit (BLD08-0164) for an unheated, unplumbed detached shop was finaled on April 13, 2009. A building permit(BLD08-0167) for a bridge access to future bldg site was approved on December 1, 2008. A building permit (BLD09-0051) for a culvert installation was approved on April 30, 2009. A septic permit(SEP09-0015)was approved on April 30, 2009. A building permit(BLD09-0146) for a manufactured home permit was cancelled on February 2, 2011. A well review(USR09-0006)was finaled on June 23, 2009. 44.) An easement was recorded on October 29, 2008 under AFN 538355 with the Jefferson County Auditor granting access to parcel 602285001 across parcel 602283007. 45.) NOTICE: This permit does noOcuse the proponent from complying with AI 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 WVESTERMAN III • Jefferson County urtl.ouse ASSESSOR Po Box 1220, Port Townsend, 'VA 98368 (360) 385.9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: D1Q1fjeOAi L °lam Pc K. ADDRESS: I3 S S &t&. nY-e 3 78" • 1(LAO-- LOit, 9 gaEl. PHONE NO. 40 . 709-( te 1340- 770 -7?0/ 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 ' a. Ter) (B) MODEL '"Or (C)YEAR i (2)I (D) LENGTH 65 14 4, (E) WIDTH o? / (F) SERIAL # Cifae l t (G) YOUR PURCHASE PRICE (Do not include sales tax) ! el PURCHASE DATE� j 1, 2)DEVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) 4 a (A) FROM WHOM DID YOU PURCHASE MOBILE ADDRESS (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No If Yes, Previous address of mobile. i � If No, What County was Mobile assessed in E j��,it\ [ 1 D 3►WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOM PA5 Yes No (B) IF LOCATED IN MOBILE HOME PARK: ir ,i r' ` 3"P NAME & ADDRESS OF PARK i Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PA K• (� NAME OF LAND OWNER: tth 1N�C,)I �.8ref ak Le-. , LOCATION ADDRESS c24 g Do5 e mitc.i kp3 Dai \r(N nor) , `4}( /05290 REAL PROPERTY PARCEL #/DESCRIPTION I G oaa g,1'"001 Signature of applicant THANK YOU FOR YOUR HELP! Lauralee Kiesel, Property Technician • G • \ - d6x66 Y a6>r55 V frl P1 21:iimi'l--4 ill a yF /^y\� Q , L y iiiiii_c_iv....) Q - tl g 1 I 1 < hYo . O4 • th a71 r 1116-L::::' C 5 //„ N al w L a al 4' es : ITEM 8 1111T 1 Rafrlp l / + F + /$ r �_ f r a ..itt Itil „. ien4).-8—L,' 4 1n$ Tel^ <- �j i�1. +Nii kiiiii� — Ilt glIPC, 7I L `1 f/ 1 °N ° • • �Aw wOdd • JEFFERSON COUNTY ' DEPARTMENT OF COMMUNITY DEVELOPMENT s'4 621 Sheridan Street• Port Townsend •Washington 98368 4 360/379-4450 • 360/379-4451 Fax 1 14e www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: I (" 3 I Project Dgscriptipn(include separate sheets as n4cessa y): 14)STa ll t(hil © 1 rQU'b le,-1t,Y4 (jnm Tax Parcel Number: (,t 0112 a'S'UO/ Property Size: I iU/e (acres/square feet). Site Address and/or Directions to Property: aG$z2 Jose mialias gas, grl'o/7ri la 98 Property Owner(s)of Record: ciia-tie-ei.ebd lte)/Pe.r) /A.PK Telephone: - O - ' ? 04'-Fax: "-t ''I email:Mere ••e s60 �. �c:aket . Mailing Address: /3 3 $ 0/ # 7 ';ped ro-lao-D// f IVA 98g. % effrou Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies 0 Lot or Road Segregation j 3uilding 0 Critical Areas Stewardship Plan ❑ Demolition Permit 0 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 •�Commercial* • - ❑Discretionary"D"or Unnamed Use Classification. 0 Special Use(Essential Public Facilities) 0 Change of Use 0 Boundary Line Adjustment 0 Address 0 Road Approach 0 Short Plat** ❑Home Business 0 Cottage Industry 0 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 ❑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 Mas er P t,•r dip t *May require a Pre-Application Conference 0 Tree Vegetation Request �� i Iq **Requires a Pre-Appl cati•�If\•. ,.,ence J1 ' Please identify any other local,state or federal permits required for this proposal, if known: FEB 15 2011 DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application�for peelrrnitt'(s,. OWNER SIGNATURE Date. JE.I ' Ul1El/ ti t i11i� 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 inspection . Staffs access and right of entry w'Il be assumed unless the applicant informs the County in writing at the time of the pi' tion t at she t prior notice. Signature: \ Date: 1T'1/ 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 complia with the Jefferson County develo ent code.The Applicant acknowledges that he,she or it holds individual and non-tr erable p sibil' dhering to an mplying ' e A T Applicant has read this disc)�jimer7a d 7ns and dates it below. Signature: Date: or .1 -1 • • 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 a ing th= - .onsibility•-General Contractor for the proposed project. 'A Signature: "` Ilk -.,_ Date: Z 7, 51 f 1 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ' ' ARCHITECT/ENGINEER: PHONE ( . ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New ❑ Wood Existing: ❑ Sewer 0 Addition ❑ Steel Proposed: • Bank ❑ Community System ❑ Alteration/Remodel . ❑ Concrete Total: Height: 'Individual System O Repair ❑ Masonry SEP Permit# ' ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: "90.,. Private well 0 Two Party Ty p,p pf Heat: Proposed: ❑ Public (- IQ C hf i C. 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: 1 Underground Tank 1 Above ground Tank Size of Propane Tank: 1 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. r��� �c ,kx� K „ S.uare Foota•e Current Proposed `rt 6ti'i ,j ..,�. .! t,r.p4 iv, ' : a tt1 )1.0, r E,i q�._...r),3, ,;._.' Main Floor Heated 0$ EH Bld App Review: 2"°Floor Heated ` 4` "f ` Consistency Review: Other Heated Base fee: ( �_.� Mezzanine ` s ; Additional Section: " 0 _ _ © ii , . " Plan Check fee: Heated Basement - © _ -- © -- t Unheated Basement h,`p'� w. State Surcharge fee: Other Unheated fis Pot Water Review fee: Garage/CarportSUBTOTAL r jJ / Oj(jJ Y Decks t , Y 911/Rd Approach fee: p - - 0 - O ��t Other TOTAL: $ aG ;: , Receipt Number: I c°-3c-)l3 µ .� ` Cash/Check Number: ffI / _ ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish ( ` ID-. I I Initials: .-.... •.�. ai..irr-.-.n�rouuu .�n.�nr.n.rn �._.__...n..r_ .--_ �r__...n.__.. ...._'•_-"_.r..n nn n__ . rt., ilk N 'W —a, res Va . � .a sco;N : E0 o O • g381 � 3 ` cO _` 0 d� 3 arD / 0 c. � / a y r.-- � 7 . "8:8::ti.gig 1 3::: i.co,..:3"lal ! =I \ 1 1 a Pa na gf '' G' h !-fHF II HU• , fl ` m c. 2Sm ffnn m 1 3 0 = °. ?, \1 \. \ •, n• o aka / o =a m H' m'Z. ° 4' N _ taC1 I " 'aoCa.8 ;8 . 2.�� �_ ----- . 4 t. g 8 °' i4 °\ iii q1 • /N. 1 C., e a- Q� ---, (.., ...444440k AI 8 Sti •, w ij• 6 / E J I! ( ' D. ..-. \ , , • , V!illi• . 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