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HomeMy WebLinkAboutBLD2012-00326 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 #: BLD12-00326 SITE ADDRESS: 4723 CENTER RD Issue Date: 01/28/2013 CHIMACUM, 98325 Final Date: 11/1/2013 APPLICANT: ROGER L BROWN PHONE: 360-732-0506 MARIE A BROWN PO BOX 1043 PORT HADLOCK WA 98339-1043 SUBDIVISION: JOHNSTON SHORT PLAT Block: Lot: 3 PARCEL NUMBER: 801034015 Section: 3 Township: 28 N Range: 01 W PROJECT DESCRIPTION: M/H REVISION 1/10/13 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 11/1/2013 \\tidemark\data\forms\F_B LD_Occupancy.rpt 11/18/2013 MANUFACTURED/MOBILE HOME INStALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD12-00326 Received Date: 10/16/2012 SITE ADDRESS: 4723 CENTER RD Issue Date: 1/28/2013 CHIMACUM, 98325 APPLICANT: ROGER L BROWN MARIE A BROWN PO BOX 1043 PORT HADLOCK WA 98339-1043 SUBDIVISION: JOHNSTON SHORT PLAT Block: Lot: 3 PARCEL#: 801034015 Section: 3 Township: 28 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 DEALER 31 HIDDEN TRAILS RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2014 PROJECT DESCRIPTION: M/H REVISION 1/10/13 MAKE: FLEETWOOD YEAR: 1987 SIZE: 27X66 Directions To Site: To schedule inspections, call (360)379-4455 no later than 3:00 PM the day before the inspection is needed. Requests received after 3:00 PM will not be scheduled for the next day's inspections. Office Hours 9:00 -4:30 MONDAY-THURSDAY 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 Center Road right-of-way shall be 30 feet. Minimum north and south property line setbacks shall be 5 feet. Minimum setback from the edge of the wetland shall be 90 feet. Minimum setback from the OHWM of the stream shall be 80 feet. Erosion Control SEE CONDITION 2 Erosion Control MH Foundation 11-I _ 13 Blocking&Tie Down , I - 13 9N— Skirting&Ventilation 1 I_t - 13 , Drywell/Alt Drainage 1 I - ) - t3 ,S2, SEE CONDITION I FOR SPLASHBLOCKS Address Posted ) , - i 3 Water Meter Inspection FINAL INSPECTION , ; E - l .1 FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR MLA12 BUILDING PERMIT APPLICOION Review 00229 Review Type: I Jefferson County Department of Community Development 4-'1\5)6C\ 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD12-00326 Received Date: 10/16/2012 SITE ADDRESS: 4723 CENTER RD CHIMACUM, 98325 OWNER: ROGER L BROWN PHONE: 360-732-0506 MARIE A BROWN PO BOX 1043 PORT HADLOCK WA 98339-1043 JOHNSTON SHORT PLAT SUBDIVISION: Block: Lot: 3 PARCEL NUMBER: 801034015 Section: 3 Township: 28 N Range: 01 W CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 31 HIDDEN TRAILS RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2013 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI` M/H W/ DECKS - M/H REVISION 1/10/13 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,716 VALUATION 1,000.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2009 OCCUPANCY: HEAT BASE: HEAT TYPE: WOD OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: SHORELINE: GARA CONST TYPE: DECKLE 128 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 1PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Natal' 2 Routing Date: ICE I Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $222.00 LYK 10/16/12 135304 Permit $97.25 LYK 10/16/12 135304 Plan Check $63.21 LYK 10/16/12 135304 State Building Code $4.50 LYK 10/16/12 135304 Potable Water Application $64.00 LYK 10/16/12 135304 Total: $450.96 \\firlcmor4\rlofo\fnrmo\C RI Il Ann PIA rnf 1/1n/7n1Z • • SPECIAL CONDITIONS CASE # BLD12-00326 1.) DESIGN CRITERIA FOR SPLASH BLOCKS: A VEGETATED FLOWPATH OF AT LEAST 50 FEET SHOULD BE MAINTAINED BETWEEN THE DISCHARGE POINT AND ANY PROPERTY LINE, STRUCTURE, STEEP SLOPE, STREAM, WETLAND, LAKE, OR OTHER IMPERVIOUS SURFACE. SENSITIVE AREA BUFFERS MAY COUNT TOWARD FLOWPATH LENGTHS. A MAXIMUM OF 700 SQUARE FEET OF ROOF AREA MAY DRAIN TO EACH SPLASHBLOCK. A SPLASHBLOCK OR A PAD OF CRUSHED ROCK(2 FEET WIDE BY 3 FEET LONG BY 6 INCHES DEEP) SHOULD BE PLACED AT EACH DOWNSPOUT DISCHARGE POINT. NO EROSION OR FLOODING OF DOWNSTREAM PROPERTIES MAY RESULT. FOR SITES WITH SEPTIC SYSTEMS, THE DISCHARGE POINT MUST BE DOWNSLOPE OF THE PRIMARY AND RESERVE DRAINFILED AREAS. 2.) 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. 3.) The existing travel trailer that is occupied and directly connected to the septic system MUST have the connection removed and the trailers use converted back to a non residential use, (receational use only) ONLY ONE LIVING STRUCTURE ALLOWED ON THIS SEPTIC SYSTEM/PROPERTY. 4.) The project is located within WRIA 17 and thus is subject to compliance with the WA State Department of Ecology In Stream Flow Rule for that region. The parcel is located within the Chimacum sub-basin; as such, state regulations require the following: 1. Water use shall be limited to domestic use only, and such use shall not include outdoor irrigation. "Domestic use" means use of water associated with human health and welfare requirements, including water used for drinking, bathing, sanitary requirements, cooking, laundering and other incidental household uses, including potable domestic water requirements associated with commercial and industrial purposes. (WAC 173-517-150(8)) 2. INSTALLATION OF A WATER METER, MEETING DEPARTMENT OF ECOLOGY SPECIFICATIONS, IS REQUIRED FOR ALL NEW USES THROUGHOUT THE WATERSHED. (WAC 173-517-180) BROCHURES WITH SPECIFICATIONS ARE ENCLOSED WITH THE PERMIT. Refer to enclosed documents for more information, see Ecology web site at http://www.ecy.wa.gov/programs/wr/instream-flows/quilsnowbasin.html or contact Ecology at 360-407-6300. 5.) The application was revie•by the Jefferson County Department of Ganunity Development staff on November 8, 2012 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: Type N stream; category III wetland; SUSC aquifer recharge area; forest land adjacent. 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.) A Type N Stream (Fish and Wildlife Habitat Conservation Area) has been identified on the subject property. The stream will require a buffer of 75-feet. The buffer shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 9.) Stream and wetland 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. 10.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea sitchensis), Shore Pine (Pinus contorta), Douglas Fir(Pseudotsuga menziesii), Western Red Cedar (Thuja plicata), and Western Hemlock (Tsuga heterophylla). Among native tree species which may be used includes: Vine Maple (Acer circinatum), Big-Leaf Maple (Acer macrophyllum), Red Alder(Alnus rubra), Pacific Madrone (Arbutus menziesii), Quaking Aspen (Populus tremula), Black Cottonwood (Populus trichocarpa), Bitter Cherry (Prunus emarginata), Oregon White Oak (Quercus garryana), Cascara (Rhamnus purshiana), Pacific Willow(Salix lasiandra), and Scouler's Willow(Salix scouleriana). Among the native shrub species which may be used are: Sevice-Berry (Amalanchier alnifolia), Red Osier Dogwood (Cornus stolonifera) Sala! (Gaultheria shallon), Ocean Spray (Holodiscus discolor), Indian Plum (Oemlaria cerasiformis), Pacific Ninebark (Physocarpus capitus), Red Flowering Currant(Ribes sanguineum), Wild Rose (Rosa nutkana), Swamp Rose (Rosa pisocarpa), Willows (Salix ssp.), Red Elderberry (Sambucus racemosa), Snowberry(Symphoricarpos albus), Evergreen Huckleberry (Vaccinium ovatum), Red Huckleberry(Vaccinium parvifolium). 11.) A setback of 90-feet, measured perpendicularly from the wetland edge, shall be permanently maintained as a buffer. No filling, grading, clearing, or other alteration of the wetland or its buffer is allowed. 12.) Wetland 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 contain the following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation." 13.) A permanent physical separation along the upland boundary of the wetland 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. 14.) 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. 15.) The identified Fish and Wildlife Habitat Area (Type N Stream), 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 manufactured home. 16.) An additional setback of five (5) feet is required from the edge of the stream buffer area to the proposed manufactured home. 17.) 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. 18.) Stream buffer perimeters al be marked with temporary signs at an inal 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." 19.) The applicant is proposing to create or add 2504 square feet of impervious surface and 2188square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution Prevention) of the Department of Ecology Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 20.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 21.) 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). 22.) The site plan as submitted with the manufactured home installation application on October 16, 2012 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 26, 2012 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 23.) This approval is for a manufactured home installation 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. 24.) The parcel has been designated as RR 1:10 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 25.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 26.) 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. 27.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 28.) 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. 29.) 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. 30.) Minimum setback from Center Road right-of-way shall be 30 feet. Minimum north and south property line setbacks shall be 5 feet. Minimum setback from the edge of the wetland shall be 90 feet. Minimum setback from the OHWM of the stream shall be 80 feet. 31.) The building height is not to exceed 35 feet. 32.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 33.) An address of 4723 Center Road, Chimacum has been assigned to the parcel. Center Road is a county major collector(C931507). 34.) The parcel is served by an on-site individual well. 35.) The parcel was created through the Johnston Short Plat on January 8, 1979 under AFN 255073. 36.) A Stormwater Managemerrmit(BLD04-00350)was approved on Jt22, 2004. A buffer revegetation plan prepared by Olympic Wetland Resources dated May 2004 was approved as a part of the stormwater permit approval. A vegetation request(ZON07-30) was aprpoved on April 12, 2007. A complaint case (COM03-38) for a zoning violation was finaled on March 10, 2008. A complaint case (COM06-013) for alleged stormwater problems and complaint case (COM99-65) for filling in a wetland were finaled on November 21, 2012 as a stormwater permit(MLA04-316)was submitted, reviewed, and finaled on August 24, 2007 to remove up 800-cubic yards of material from the wetland buffer. A complaint case (COM07-124) for allegedly flooding neighboring yard from failing stormwater plan is pending. A road approach permit(RAP06-221)was cancelled on November 3, 2006. A septic permit(SEP04-69) was finaled on August 22, 2008 and is now filed with SEP07-320 that was denied. A well review(USR99-22)was approved on September 28, 1999 (owner stated well was not drilled but Dave Christianson recalls having inspected the well seal). A well review(USR03-42)was approved on July 21, 2005. A wet season evaluation (OTH06-08)was finaled on Aprl 22, 2006 and a wet season evaulation (OTH07-11) is pending. A violation (VIO09-68) for a confirmed and suspected well contaminated (per DOE) is pending (Ecology site ID#1079161 and Ecology ERTS#554326). 37.) NOTICE: This permit does not excuse the proponent from complying with other 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. \\tidemark\data\forms\F_BLD_Perm it_Mobile.rpt 1/28/2013 SpAeJEFFERSONDUNTY • DEPARTMENT OF COMMUNITY DEVELOPMENT ' 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax www.co.jefferson.wa.us/commdevelopment �HINp�' Master Permit Application MLA: _ Z2 1 Project Description(include separate sheets as necessary): Tax Parcel Number: `r CD i o'* ("N F Property Size: 1 , `� (acres/square feet) Site Address and/or Directions to Property: 4/ 7Z..5 Cent-' ' rid • C11InZc.> c ctm rck2c. cieF)?7 Property Owner(s)of Record: ---g„r t,( ,LY,r\ me`-4 "-Qz.1-0 V�-1 Telephone: A(00 -7 2,7 • c,mac:t v Fax: email: Gihri-tnc';M Mailing Address: R• 0- c,X 10'-/„. y 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 ]Building 0 Critical Areas Stewardship Plan ❑ Demolition Permit 0 Variance(Minor,.Mlajor, or Raatnnable Economic Use) ❑ Single Family 0 Garage Attached/Detached 0 Conditional Usb[CO),r, . , ; j A y7 • Manufactured Home .0 Modular • • .• 0 Discretionary ub"i of I '-' a�.i1(fi ❑ Commercial* ❑ Special Use(Essentifal Public Facilities Change of Use 0 Boundary Line Adjustment ❑ Address 0 Road Approach_ 0 Short Plat** OCT j , 2012 ❑ Home Business 0 Cottage Industry 0 Binding Site Plan* ' ❑ Propane 0 Long Plat** ❑Sign 0 Planned Rural Residentia )/Am dments** ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Altera;kion C011MU"'ITy DE ❑Stormwater Management 0 Shoreline Master Prdgra poor nit-, ns** ❑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 ❑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 to act as my agent in matters relating to this application for permit(s). • OWNER SIGNATURE Date: 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 inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the applica!on that he or she wants prior notice. Signature': Date: \CY-? 3 -' 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 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: Date: \0'�`t�-- • 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 INSTALLER: PHONE: FAX:( ) _. 1.. ., • EMAIL: MAILING ADDRESS: CONTRACTORS LICENSE WAINS NUMBER: — NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Type:T e: Bathrooms: Shoreline: Type of Sewage Disposal:Ve New „XWood Existing: E Sewer Alteration/Remodel Proposed: Bank Community System C Add rati . - on/Remodel 0 Concrete Total: 2 Height: IS Individual System SEP Permit# �L)'�G�— C Repair C Masonry Bedrooms: Water Supply: L Demolition Other: Existing: 1 Setback: X Private well 0 Two Party Proposed: ❑ Public Type of Heat: Total: a. Name of System: ilec }-ciciwonri 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 • Type BC Occupancy: IBC T e of construction: Will you have Food Service? Yes I 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 I Other Is this appliance being installed in a Manufactured I Mobile Home? Yes / No . • When applying for a permit to install a propane tank you must also submit site plan showing all of he Y ildings,all property property lines, tank location and size, distances from the propane tank to alllines,buildings and septic s stem com onents, including the reserve area. 1110 Amount evision` Square Footage Current Proposed For Office Use Only. I Main Floor Heated EH Bid App Review: �� ' o 2_Zca r��-<) 1' Ilo 2nd Floor Heated - Consistency Review: 222 '7Z0' Other Heated Base fee: Mezzanine f3L 4._ (IT 25 - Heated Basement _ _ Plan Check fee: CD3 Zj Unheated Basement —_ State Surcharge fee: -�- 4-1', e Other Unheated — Pot Water Review fee: ( 03-- Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: XtSrf l i CI Other - TOTAL: $ �,q Q•iV �,i� IZ} Receipt Number: 2 33—1, qFes 1 Cash/Check Number: ESTIMATED COST(REQUIRED) Date: _ �� 'Fair market value of all labor and materials foundation to finish --- oco/ Initials: _ Z r-.\n>...,;rCrnrer\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Aoolication 5-29-08.doc JACK WESTERMAN 110 Jefferson C Courthouse ASSESSOR PO Box 122 . Port Townsend, WA 98:J68 (360) 385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME:—Rn e L, pro c� ADDRESS: c. o , six ktY4 ?©rt *d\ocl . t3 I ctR 3a`k PHONE NO. 3(QL1 `l 3 —O 5a(.Q 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 F kee t e O d (B) MODEL�clCC' {\c*f\ (C) YEAR \ t9 1 (D LENGTH � •(0) (E) WIDTH D6: (F) SERIAL # t !\ F L E A Z NG 15\a13o1 1 "1 xi=N, ' ASE PRICE (Do not include sales tax) o'er°-SC2:10«' PURCHASE DATE k' (o 13 2,_' '.. Ngle : OWN 1 ! CATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) `I* M 'HO I I YOU PURCHASE MOBILE ' _1 PC, AEU: S h� (B) W t. ;fHOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes No \> '� \O ress of mobile. pEF���GD If No, What Coun' Yes, Previous ty wasMobile assessed in lastyear. K 1*.4 t � � ,p 3►WHERE MOBILE HOME IS TO BE LOCATED: (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: 'BoP L, (b lJ.T v LOCATION ADDRESS '-V1 a.3 C e_n r onar , to A S 3 aS REAL PROPERTY PARCEL #/DESCRIPTION �0\ ("Y -\ 0\ t . 53 Accp 5 Signature of applicant THANK YOU FOR YOUR HELP! Lauralee Kiesel, Property Technician .------ • ii , . .. -N. s REVISED SI1 PLAN /1N dated 1 I ID1 i3I/ Y;- . - "` ` Has been APPROVED t j kd /3 \ by JEFFERS�i OUN i {I ,.EV LO• ) N DEPT.OF •� �'��' � r S1ONATU'�': i ► .i�.I mi la-a,c a-3acp -----.. ----- too ', rlan oCad-v - h 07\12-v- cony decI si o0 - boi'ldh: c . Sh !ae- Low ,eYt 00i-side, o 40 w la 44 ; l -- _ , bt)- 6 4- 1/4-5-1-"cl/n1 .bqle'r oc IC ,\ �� I , ',I j Ui\,\ I •L/1�U'3 6`O'Po ''y'FI fPMENT • c��\\�z SO'P,y��P / Approximate edge of Right of Way 700' Setback o „�o0 r Top of�ian ' U, ,/ /I / t �os / \ e .% '! j � lt N ..N_-4 1 p • W m • 100%Primary o, 1 8' K 50' Sandlined Bed / ,� Appro�cimate Location of Existing Trailer � /// tam bs� -�►, . I St2�tic�n1�+ ii A., "0 • Imo. I ' 1 144,- , ' ` qL € I3tr C �( c2I 1ack to ea. ' r1 `ll0se twetay ;, ' , pia'-� t_5 (O I ' \30' ct�.ss •I aseme ,- , ic g2-f iUn \ 1 I/1 - ' : . Nlik ‘, ______7\ \ • u,. k'eptic&Pump tanks '�, -- I o�,�e ,g(o ).gX( ,1 �• I; \, 1`1.4 rr.`, Y,r+Ll i. .Vv..,_ , 0,, --...... / ,, 1. / • N 89°43'22" W Existing Well \ (-), Easement ,•'-` 1.1111. ---• . . .... ,i *** . . , •... . i• 4.. NI *:? j s i 1U rf 14 c.... :: I . 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