HomeMy WebLinkAboutBLD2012-00354 S
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#: BLD12-00354
SITE ADDRESS: 2714 CHICKEN COOP RD Issue Date: 11/15/2012
SEQUIM, 98382 Final Date: 1/16/2013
APPLICANT: SEQUIM LAND 1 LLC PHONE: 360-582-9330
65 JUNIPER MOBILE EST
SEQUIM WA 98382-3250
SUBDIVISION: RAINIER EVERGREEN SHORT PLAT Block: Lot: C
PARCEL NUMBER: 902042022 Section: 4 Township: 29 N Range: 02 W
PROJECT DESCRIPTION: M/H - SER# 2K91-0191-H
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2009
EDITION.
OCCUPANCY GROUP:
TYPE OF CONSTRUCTION:
SPRINKLER SYSTEM yes
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 1/16/2013
\\tidemark\data\forms\F_BLD_Occupancy.rpt 1/16/2013
I
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 #: BLD12-00354 Received Date: 10/31/2012
SITE ADDRESS: 2714 CHICKEN COOP RD Issue Date: 11/15/2012
SEQUIM, 98382
APPLICANT: SEQUIM LAND 1 LLC
65 JUNIPER MOBILE EST z`�3
SEQUIM WA 98382-3250
SUBDIVISION: RAINIER EVERGREEN SHORT PLAT Block: Lot: C
PARCEL#: 902042022 Section: 4 Township: 29 N Range: 02 W
CONTRACTOR/ OWNER/BUILDER PHONE:
DEALER
PROJECT DESCRIPTION: M/H -SER#2K91-0191-H
MAKE: HOMETTE YEAR: 1994 SIZE: 66X14
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.
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 t
Erosion Control SEE CONDITION 2
MH Foundation ;1,2 _I L U
Blocking&Tie Down U
1 2.1"\Z9-1-
Skirting&Ventilation
Drywell/Alt Drainage SEE CONDITION I FOR DRYWELLS
Address Posted
Water Meter Inspection
1- tv` �i .l
FINAL INSPECTION \ —((2-1 , f�
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
SPECIAL CONDITIONS APPLY -SEE REVERSE
ItILDING PERMIT APPLICAT�N MLAI2-00243
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00354 Received Date: 10/31/2012
SITE ADDRESS: 2714 CHICKEN COOP RD
SEQUIM, 98382
OWNER: SEQUIM LAND 1 LLC PHONE: 360-582-9330
65 JUNIPER MOBILE EST
SEQUIM WA 98382-3250
RAINIER EVERGREEN SHORT PLAT
SUBDIVISION: Block: Lot: C
PARCEL NUMBER: 902042022 Section: 4 Township: 29 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 924
CODE EDITION: 2009 ADD'L: HEAT TYPE: EEE
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: 1PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 2
Total: 2 Total: 2 77->
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $222.00 LYK 10/31/12 136367 APPROVED
Potable Water Application $64.00 LYK 10/31/12 136367
Total: $286.00 NOV 15 2012
.;offer= County Planet;ng
& Building Department
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• •
SPECIAL CONDITIONS CASE # BLD12-00354
1.) 2012 DOE STORMWATER MANUAL DRYWELL DESIGN CRITERIA
ALL INFILTRATION SYSTEMS SHOULD BEAT LEAST 10 FEET FROM ANY
STRUCTURE, PROPERTY LINE, OR SENSITIVE AREA.
FOR SITE WITH SEPTIC SYSTEMS, INFILTRATION SYSTEMS MUST BE
DOWNGRADIENT OF THE DRAINFIELD UNLESS THE SITE TOPOGRAPHY CLEARLY
PROHIBITS SUBSURFACE FLOWS FROM INTERSECTING THE DRAINFIELD.
DRYWELL BOTTOMS MUST BE A MINIMUM OF 1 FOOT ABOVE SEASONAL HIGH
GROUNDWATER LEVEL OR IMPERMEABLE SOIL LAYERS.
EACH DRYWELL MAY SERVE UP TO 1000 SQUARE FEET OF IMPERVIOUS
SURFACE FOR EITHER MEDIUM SANDS OR COURSE SANDS.
TYPICALLY 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.
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 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 Miller sub-basin in a designated Coastal Management Area; as such, state regulations
require the following:
1. 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.
4.) This building approval accounts for 240 GPD of septic system capacity, as designed and
approved SEP11-69 is sized for only one single family residence. It is not sized for an
Accessory Dwelling Unit(ADU). The minimum daily design flow per residence is 240
GPD.
5.) 10' minimum separation required between the water line and any onsite sewage system
components including sewage transport lines.
6.) SEPTIC SYSTEM COMPONE•ETBACKS TO STORMWATER MANAG•NT
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.
7.) The application was reviewed by the Jefferson County Department of Community
Development staff on November 9, 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
Ns/Np streams, seismic.
8.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
9.) Two Type Ns/Np Streams (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.
10.) 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.
11.) 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) Salal (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).
12.) The identified Fish and Wildlife Habitat Areas (Type Ns/Np Streams), shall maintain a
vegetative buffer setback of 75-feet from each stream. The setbacks shall be measured
horizontally from the Ordinary High Water Mark (OHWM) to the manufactured home.
13.) An additional setback of five (5) feet is required from the edge of the stream buffer areas
to the proposed manufacture home.
14.) A permanent physical separation along the boundary of the stream buffer areas 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.
15.) The applicant is proposing to create or add 924square feet of impervious surface and
3684 square 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.
16.) The project shall comply with Celtruction Stormwater Pollution Prevention•PP)
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.
17.) 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).
18.) The site plan as submitted with the manufactured home installation application on October
31, 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 13, 2012 shall be
resubmitted for review and approval by Jefferson County Department of Community
Development.
19.) 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.
20.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
21.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
22.) 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.
23.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
24.) 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.
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.) Mininum setback from Chicken Coop Road and Craig Road rights-of-ways shall be 20
feet, Minimum side and rear yard setbacks shall be 5 feet. Minimum setback from the
two streams shall be 80 feet as measured from OHWM.
27.) The building height is not to exceed 35 feet.
28.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
29.) An address of 2714 Chicken Coop Road, Sequim has been assigned to the parcel.
Chicken Coop Road is private P32).
30.) The parcel is served by an on-site individual private well.
31.) The parcel was created through the Rainier Evergreen Short Plat on December 27, 1977
under AFN 246827.
32.) A septic permit(SEP02-197)was cancelled and now filed with SEP11-69. A septic permit
(SEP05-354)was cancelled and is now filed with SEP11-69. A septic permit(SEP11-69)
was approved on October 5, 2011. A well review(USR11-36) was approved on October
10, 2011.
41111
33.) NOTICE: This permit does nol;use the proponent from complying with 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_Mobi le.rpt 11/15/2012
• •
/ JACK WESTERMAN III Jelier.en Cennty Coarthease
ASSESSOR 1'tl 13ex 1220, Pori Tewwheled, IV A 98368
(360)385.9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME:_ £ e WI try d I
ADDRESS: (p( J/,(.i,i%tack_ f 3)6/I C lvS�7L � �)ao L(iLi /Oh 7 t 7
PHONE NO. 3j6- 5 ' 2— `� 33
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous osivrn mobile
home. This will help our office determine whether tl ikiiu HOaI AWN'' on the
tax rolls in Jefferson County or if it has been moved i ,t ■s county from anet area.
OCT 3 1 2012
I)MOBILE HOME DATA: I�
EF RS CO NTY
(A► MAKE met-tf-e_,. (B) MODEL ill/��� DiF E AR Ogg
(D)LENGTH (/ (E)WIDTH I L I (F)SERIAL#
(G)YOUR PURCHASE PRICE(Do not include sales tax b i JUG'. U 0 PURCHASE DATE (DI A' )2_
20 PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 30 }� .�
(A)FROM WHOM DID YOU PURCHASE MOBILE_15 a0421,"�G't iMi 6 O set
ADDRESS l)oi (14 06/1,� �W t !o I, � 14-11-e'es GZ
(B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes CSIOD
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year. l` l<L l( } 1,1A ODIC(.1
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes Ne
(B)IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Space#
(C) IF NOT LOCATED IN MOBIL HOME PARK:
NAME OF LAND OWNER: . t(/.t_YLI C.-Q.0 I( I Lb(' _1
LOCATION ADDRESS n I L C A (('A( eriDe 12�C Situ j44 OA,
REAL PROPERTY PACEL #/DESCRIPTION /110aZa�-ov -
R ECLh ay) q, Ik r c i r.shi p fYi ti', Ret_riel r. n 5-kJ, 124111 e 4f,atit<iite
eta Pik ft;Atez
Si nature of applicant
THANK YOU FOR YOUR HELP!
(46,
COSSELL, Property Technician
I00/3O/2012 13:38 FAX • • [1 001/002
r e° . JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
44
''q 621 Sheridan Street• Port Townsend •Washington 98368
,�` 360/379-4450• 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: 1(,) ":-)L.)
P Description f separate sheets as ):
Seri' — l PI /01A/1014e P9 i it D , Wt. f�-alitili ,Et/> c% 6tik-4- PIO ` IL
Tax Parcel Number: q8A 0 i. Property Size: ((#+• 1-f .-- (Terrsquare feet)
Site Address an'd/or Directions to Property:1Ow4 s)ei 64�t is //P�f't. (Da ge.,,, g tun1 60k 96'3 p 7
Property
Telephone:, j t� ' Fax: emai: f M 41. , .//Cam
le 5- GW[i dI f` l�' C' ui�
Mailing Address: �'!�1 k_
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address: ;._ �i, `--.__; .
kind of Permit?(Check each box that applies
� ,
r""`��1� ❑Critical Areas Stewardship Plan
❑ Demolition Permit 0 Variance(Minor,Major or Reasonablg, .. • i • •
❑Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a),(a(d),or CI"LU
fErgianufactured Home 0 Modular 0 Discretionary"D"or Unnamed Use C -- •=
CI Commercial* ❑Special Use(Essential Public Facilities)" i'
❑ Change of Use ❑Boundary Line AJusERSON COUNTY
❑ Address 0 Road Approach 0 Short Rat" �T.OF COMMUNITY DEVELOPMENT
❑Home Business CI Cottage Industry 0 Binding Site Pian-
❑Propane O Long Plat"
❑Sign ❑Planned Rural Residential Development(PRRDYAmendments"
❑Allowed'Yes"Use Consistency Analysis ❑Plat Vacation/Atteration"
❑Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions"'
❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development" •
o Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* 0 Comprehensive PIaMJDC/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 Pm-Application Conference
Please Identify any other local,state or federal permits required for this proposal,tf known:
I hereby designate ��eCtnctG.h�1S t�r\b`>;Y�
DESIGNATION OF AGENT
• -. to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATU Date: to/Z 1 //z -
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 reaped 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 attomeys 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 a, • ... .. _ -. . . . . .. .... ..... -
Signature: ..._ /
Signature: 4 Date: l.� 2'7 /i 2.
The action of 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 no afereb tgfor adherinnfnAnd complying with the ESA. The nt has read this disclaimer and
� AppGca signs and tea it below.
Sig natur_--^�(, -.._„_ Date: I r9 r e-41
G:\PennitCen r\####FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
4 • •
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: ' %~M .'.�_ Date: is,f 1`.-;-/f 1--
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Pro et Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New ❑ Wood Existing: `.J ❑ Sewer
El Addition ; --'Steel Proposed: Bank ❑ Community System
O Alteration/Remodel ❑ Concrete Total: .9Li- Hei t:
Q� Individual System
O Repair C Masonry -ti' SEP Permit# 5 L-1°0 5 r 3.
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: c, Private well 0 Two Party
Type of Hey: Proposed: ❑ Public
r (` (i t-r (_ Total: Lk Name of System:
If this is a Commercial Project you must ahsw; r tha f i JJ n (1 n/] f
Number of Parking Spaces: Current: g�j1_\�/ l umber of ADA Parking Spaces:
Number of occupants(includes owners,tenahtssrriployees,etc) Current i Proposed
IBC Occupancy: IBC Type of cgn�truction;,,,T � - riiR tiljypu have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,Mark eli itet' blehldw that apply:
i Underground Tank 1 Above ground Tank! Li 111 Size of Propane"ark I
I Heat Stove 1 Cook Stove i Woodstove 1 I Fireplace[irm/of,d,,MIltrrk erkrank 1 I Pellet Stove 1 Other
Is this appliance being installed in a Manufactured/r♦ilobile,Home?7HXles,-/.TNo 1
When applying for a permit to install a propane tank youmusiiitso'submit a3ite 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.
'ems
Square Footage Current Proposed Fo,i fft "all flnly0 ,..,.,.t., .. Amount p ,fixslog-- ,
Main Floor Heated IJ,,1 . EH BId App Review:
2 Floor Heated x ;, .: Consistency Review:
222
Other Heated , 6 Base fee: .—
t Y Z22
Mezzanine " Additional Section:
Heated Basement :!, Plan Check fee:
Unheated Basement 3 State Surcharge fee:
r
Other Unheated -- Pot Water Review fee: !
x . V.
Garage/Carport SUBTOTAL
Decks - 911/Rd Approach fee:
Other . TOTAL: $
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j;: t; Receipt Number: ,5 --) ,ri
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: ,-. 1-4Z.Fair market value of all labor and materials foundation to finish I C
Initials: _______.----- _ _
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