HomeMy WebLinkAboutBLD2011-00177 •
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 #: BLD11-00177
SITE ADDRESS: 82 N PITTSBURG AVE Issue Date: 08/17/2011
PORT TOWNSEND, 98368 Final Date: 3/6/2012
APPLICANT: LI LI MEI RAIGUEL PHONE: 360-531-0481
200 W KINKAID ST
PORT HADLOCK WA 98339-9660
SUBDIVISION: IRONDALE Block: 123 Lot: 34+
PARCEL NUMBER: 962112313 Section: 34 Township: 30 N Range: 01 W
PROJECT DESCRIPTION: M/H - SER# 11818420
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 3/6/2012
I:\F_BLD_Occupancy.rpt 10/29/19
MANUFACTURED/MOBILE HOME INSTAATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00177 Received Date: 7/11/2011
SITE ADDRESS: 82 N PITTSBURG AVE Issue Date: 8/17/2011
PORT TOWNSEND, 98368
APPLICANT: LI LI MEI RAIGUEL
200 W KINKAID ST
PORT HADLOCK WA 98339-9660
SUBDIVISION: IRONDALE Block: 123 Lot: 34-40
PARCEL#: 962112313 Section: 34 Township: 30 N Range: 01 W
CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215
DEALER 1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License KOZELHS027C3 Expires 1/6/2013
PROJECT DESCRIPTION: M/H -SER# 11818420
MAKE: REDMOND YEAR: 1992 SIZE: 50X27
Directions
To Site:
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
Setbacks
Erosion Control ; _ -)r Z
MH Foundation
Blocking&Tie Down
Skirting&Ventilation _j z `
Pressure Test
Drywell/Alt Drainage
Address Posted
FINAL INSPECTION
((11-1)
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY-SEE REVERSE
RILDING PERMIT APPLICATNN MReiew001pe35
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00177 Received Date: 7/11/2011
SITE ADDRESS: N PITTSBURG AVE
PORT TOWNSEND, 98368
OWNER: LI LI MEI RAIGUEL PHONE: 360-531-0481
200 W KINKAID ST
PORT HADLOCK WA 98339-9660
IRONDALE
SUBDIVISION: Block: 123 Lot: 34-40
PARCEL NUMBER: 962112313 Section: 34 Township: 30 N Range: 01 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 1/6/2013
REPRESENTATIVE: JAIME KOZELISKY PHONE: (360) 385-3215
1112 S JACOB MILLER RD (360) 385-3215
PORT TOWNSEND WA 98368
PROJECT DESCRIPTIOr M/H - €-tk I IS 0420
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 1,400
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: CON
WATER SYSTEM: 05783
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 2
Total: 2 Tot 2
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 07/11/11 123690 APPROVED
Potable Water Application $62.00 LYK 07/11/11 123690
Total: $275.00 AUG 11 2011
Jefferson County Planning
& Building Department
• •
SPECIAL CONDITIONS CASE # BLD11-00177
1.) SEPTIC SYSTEM COMPONENT SETBACKS TO STORMWATER MANAGEMENT
FACILITIES -
Any stormwater component: dry well, infiltration trench/pond, foundation drains, or any
other source of water that is upgradient(above) or on the same contour MUST be setback
a minimum of 10' from any septic system dispersal area (drainfield) and 5' from any septic
tanks.
Any stormwater component: dry well, infiltration trench/pond, foundation drains, or any
other source of water that is downgradient or lower MUST be setback a minimum of 30'
from any septic system dispersal area (drainfield) and 5' from any septic tanks.
Surface drainage, roof run-off, splash blocks, etc. must be directed away from ALL septic
components.
2.) DRYWELL BOTTOMS MUST BE A MINIMUM OF 1 FOOT ABOVE SEASONAL HIGH
GROUNDWATER LEVEL OR IMPERMEABLE SOIL LAYERS.
EACH DRYWELL MAY SERVE UP TO 1,000 SQUARE FEET OF IMPERVIOUS
SURFACE FOR EITHER MEDIUM SANDS OR COARSE SANDS.
DRYWELLS ARE 48 INCHES IN DIAMETER (MINIMUM)AND HAVE A DEPTH OF 5
FEET (4 FEET OF GRAVEL AND 1 FOOT OF SUITABLE COVER MATERIAL).
FILTER FABRIC (GEOTEXTILE) MUST BE PLACED ON TOP OF THE DRAIN ROCK
AND ON TRENCH OR DRYWELL SIDES PRIOR TO BACKFILLING.
SPACING BETWEEN DRYWELLS MUST BE A MINIMUM OF 4 FEET.
3.) The application was reviewed by the Jefferson County Department of Community
Development staff on 8-15-2011 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, the following ESAs were
confirmed to be present on the subject property: Susceptible Aquifer Recharge Area and
Special Aquifer Recharge area.
4.) 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.
5.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special
Aquifer Recharge Protection Areas and the following land uses located within Susceptible
Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural
Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4)All
Rural Residential Land Uses with nonconforming uses that would otherwise require a
Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential
Developments (6) Unsewered residential development with gross densities greater than
one unit per acre. All of the above listed uses shall be subject to the applicable
requirements and standards of the Jefferson County Unified Development Code.
6.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
7.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
8.) VOLUNTARY MEASURES O9OASTAL &AT RISK SIPZ: •
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
9.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
10.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
11.) 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.
12.) The applicant is proposing to create or add 2,600 square feet of impervious surface and
4,800 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.
13.) 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.
14.) 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).
15.) The site plan as submitted with the Manufactured Home application on 7-11-2011 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 7-11-2011 shall be resubmitted for
review and approval by Jefferson County Department of Community Development.
16.) 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.
17.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
18.) A Declaration of Restrictive Cooant has been recorded on 8-8-2011 undeeN 561543
for the purpose of consolidating the lots to meet minimum land area requirements for
on-site septic and to allow zero lot line setbacks. The Covenant is strictly for building and
septic purposes only.
19.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
20.) 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.
21.) This parcel is within Kala Point no shooting area per JCC 8.50.
22.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
23.) The road approach permit RAP 11-00037 must be inspected and finaled by the Jefferson
County Department of Public Works prior to the final inspection/certificate of occupancy of
this residence. Contact Terry Duff, Department of Public Works at 360-385-9159 for the
final road approach inspection.
24.) The building height is not to exceed 35 feet.
25.) 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.
26.) 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.
27.) This parcel is served by a Quimper Water system.
28.) A septic permit(SEP97-00261) was approved 12-10-1997 for a capacity of 360 gallons
per day. This permit was finalled 10-11-1999.
29.) 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.
30.) Setback from N Pittsburg Ave right-of-way 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.
31.) A septic permit(SEP97-00261) was approved on 12-10-1997 and finaled on 10-11-1999
for 360 gallons per day.
32.) N Pittsburg Ave (P490) is a Private_road. A road approach (RAP011-00037)was
approved on 8-16-2011 and an address of 82 N Pittsburg has been assigned to the
parcel.
33.) NOTICE: This permit does noocuse the proponent from complying with •r 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
The Federal Bald and Golden Eagle Protection Act requires landowners within 660 feet
(1/8th of a mile) of an eagle nest to consult with the US Fish and Wildlife Service. This
Eagle Act prohibits anyone from "taking" bald eagles. This federal law defines the term
"take" and describes the possible legal consequences when a"take" occurs. Among
other actions, "take" includes a disturbance of bald eagles or their habitat. Under federal
law a permit may still be required for activities that impact bald eagles or their habitat.
Contact the US Fish and Wildlife Service (http://www.fws.gov/pacific/eagle/) to learn more
about how this law affects your project.
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 Count•nrtlwuse
ASSESSOR PO Box 1220, Port Townsend, WA 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: LI LI I'+r1E l RA14-14EL
ADDRESS: ZOO W V.-I N V.-h NE Pa 2-T t-t r4 Y�Loc iL.. 1 ,..k,A dt 339
PHONE NO. S 3 I - d t g l
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.
',MOBILE HOME DATA:
(A) MAKE ge�h i 4 N (B) MODEL (C) YEAR 1 ICI Z
(D) LENGTH ..c-0 (E) WIDTH 2-7 (F) SERIAL # 11 e IC H 7.-0
(G) YOUR PURCHASE PRICE (Do not include sales tax) PURCHASE DATE
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE I A-1 1A (at ttati'1fS
ADDRESS W 14%.1 I 0 I Qk t 44-1 / ")/-
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes CO
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year. 0 L ALLA VVI
3)WHERE MOBILE HOME IS TO BE LOCATED: /�
(A) WILL THE MOBILE HOME BE IN ItO i&i.E P�ICKE SiNo
II II
(B)IF LOCATED IN MOBILE HOME PAIlll1;�
NAME & ADDRESS OF PARK 1 1 ! ,111` 1 I Li!i i Lot/Space #
i; L1 -�/
(C) IF NOT LOCATED IN MOBILE HOMEJPA1Ii-K:
NAME OF LAND OWNER: Li Li tV4 cErafFE J\'IIYDEW LT
LOCATION ADDRESS (Pe-Obli1/4)6) 0 P 1 -1-'M e)(.40-6- r4UE
REAL PROPERTY PARCEL #/DESCRIPTION q (0,Z- 1 12 3 13
c -
ignature of applic nt
THANK YOU FOR YOUR HELP!
Lauralee Kiesel, Property Technician
• .
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irk
w DEPARTMENT OF COMMUNITY DEVELOPMENT
` "' 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
, p*P www.co.jefferson.wa.us/commdevelopment
87Na 1.
Master Permit Application MLA: 1 1 -1 55
Project Description(include separate sheets as necessary):
Tax Parcel Number: en Z I I Z 3 / 3 Property Size: 1 Op X /cc (acres/square feet)
Site Address and/or Directions to Property: ( Mt("<.) 6 c -.
4. P i'I Tez. 131~84- ST' S • a F 1 S LA N1 V i. - ) a rJ t , S r 42
Property Owner(s)of Record: Li L I ME1 2i41 G.%w G L
Telephone: ;bp - S 1 - O ki S l Fax: email:
Mailing Address: 2-OO W -' tv -A-tt 1011- k A-N Lo L. i . I w A. 9$ 3,31
Applicant/Agent(if different from owner): �,J141 ME tl•o2 c Li S it
Telephone: 3bO• b 4 3' I Z07- Fax: 4'0-S g s'—'3 .,r email: ILo -t iJ C- tQ� Cry • cool
Mailing Address: 6 3 .N . 641.4 A-VE it-
1
PD Q-T W r'\ �� % 6,...)A st A 3 j�,
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
❑Building 0 Critical Areas Stewardship Plan
❑ Demolition Permit 0 Variance(Mino , -• - .. _ . . •.•• -
❑Single Family 0 Garage Attached/Detached 0 Conditional Us: �-• • • _ I ` ,
Nt Manufactured Home .❑ Modular • .. • - 0 Discretionary"I) •L•• ' .• r
❑ Commercial* 0 Special Use(E. -1 Public Facilities)**
❑ Change of Use 0 Boundary Line t ' t ent I
❑ Address 0 Road Approach 0 Short Plat** J U L 1 1 2011
❑ Home Business 0 Cottage Industry 0 Binding Site PI: *
❑ Propane ❑Long Plat**
❑Sign -- 0 Planned Rural "esidential Jli(MAISEpheeppifRRD)/Ame •ments**
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/ -ratI 111*DFCOMMUNITYDEVELOPMENT
❑Stormwater Management ❑Shoreline Master Program Exemptio 'error -evisions**
0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑Temporary Use 0 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:
•
DESIGNATION OF AGENT
I hereby designate` }►�E 1-t t.� to act as my agent in matters relating to this application for permit(s).
q 1 Q,�/VWNER SIGNATURE L/ L�' t Date: -ZS- 2...o
By signing this application form,the owner/agent attests ti' the information provided herein,and in anyattachments,is true and correct
ct 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 ack
may result in this permit being null and void.
Ppacket
I
further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the appli tion that he or she wantspcior notice. /f
'Signature: /7 <. 1 -t- l Date: J/4- / / ::e>//
The action or actions Applicant will undertake a§ result of the issuance of this permit may negatively impact uporrone or more threatened or
endangered species and Could lead to a potential"take"of an endangered species as those terms are detined in the federal law known as the
"Endangered Species Act"or"ESA.'Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable\responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
, Signature: , Z_____I /, �
, , (I
:f
j at L,� Date: i
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 O/R MANUFACTURED HOME INSTALLER: PHONE: FAX:
Y,OZe taste(Il 4f W1E SAC. ► t'I C . (341., 3%5'- 3'. I,r (ec) SA wic.
MAILING ADDRESS: ,S 3 N . GARS A- .E: i P.^r. EMAIL 140 2.1 N C. e Q Q . c o M
CONTRACTOR'S LICENSE WAINS
NUMBER: 1'.ts2C LNS ;Z7C 3 NUMBER 0 (..IG
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
6 New 0 Wood Existing: _ ❑ Sewer
❑ Addition 0 Steel Proposed: 2 _ Bank 0 Community System
_
❑ Alteration/Remodel 0 Concrete Total: _..92 __ Height: �( Individual System
O Repair ❑ Masonry SEP Permit# 11-0Zip
O Demolition lY Other: Bedrooms: Water Supply:
`,n A"b Existing: 4.... Setback: ❑, Private well 0 Two Party
Type of Heat: N0141E
Proposed: Public
E Le.L Total c 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 F.00d'Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
1 Underground Tank T Above ground Tank Size of Propane Tank:
I Heat Stove i Cook Stove 1 Woodstode I Fireplace Insert j Hot Water Tank I 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.
1Wk tH t'"W. Ems.-. r.,, __a9 dT s ;- 'ti
9i c 5 -46 ys i"2} -t;�.. .47Re ioli. ..r. ;.;.
Square Footage Current Proposed ,�, the U�, ..... ,� .-- �'
•
Main Floor Heated - 7 EH BId App Review: f--
2,-Floor Heated art Z~ti : Consistency Review:
ss
Other Heated { Base fee:
Mezzanine tixt-,,4 - Additional Section:
r.
Heated Basement i.- ,, Plan Check fee:
Unheated Basement `,." State Surcharge fee:
Other Unheated" J Pot Water Review fee:
1LO
Garage/Carport `A SUBTOTAL
�' ' 911/Rd Approach fee:
Decks a t.
Other TOTAL: $
;fi Receipt Number: .1 2_ Coqb
Cash/Check Number: ,( __
ESTIMATED COST(REQUIRED) Date: �]�� t"
.Fair market value of all labor and materials foundation to finish
Initials: 7�-�"