HomeMy WebLinkAboutBLD2013-00121 • III
BUILDING PERMIT APPLICATION BLD13-00120
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD13-00121 Received Date: 4/17/2013
SITE ADDRESS: 2682 RAIN FOREST RD
FORKS, 98331
OWNER: PAUL D ERICKSEN PHONE: 360-477-9335 or
CINDY S ERICKSEN 477-8030
92 RUBY RD
PORT ANGELES WA 983629127 RAIN FOREST#1
SUBDIVISION: Block: Lot: 7
PARCEL NUMBER: 991500007 Section: 30 Township: 27 N Range: 10 W
CONTRACTOR: BOYNTON CONSTRUCTION INC PHONE: 360-460-7747
117 CHAMPION RD
PORT ANGELES WA 98362
Contractor's License BOYNTCI952OM Expires 10/1/2013
REPRESENTATIVE: TRACY GUDGEL PHONE: 360-417-0501
ZENOVIC
301 EAST 6TH STREET, STE 1
PROJECT DESCRIPTION NEW SINGLE-FAMILY RESIDENCE
FLOOD DEVELOPMENT PERMIT
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 978
VALUATION 120,028.00 ADD'L: 460 HEAT TYPE: RAD
CODE EDITION: 2009 HEAT BASE: HEAT TYPE: WOD
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: SETBACK:
DECK: 320
BANK HEIGHT:
SEWAGE DISPOSAL: OSS
WATER SYSTEM: 00445
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 1 Prop: 1
Total: 1 Total: 1
Routing Date: L�/0
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,111.35 ZAL 04/15/13 140240 _ _
Plan Check $722.38 ZAL 04/15/13 140240 R L)
State Building Code $4.50 ZAL 04/15/13 140240
Potable Water Application $66.00 ZAL 04/15/13 140240 JUN 13 2013
Total: $1,904.23 Jefferson County DCD
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1
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#: BLD13-00121
APPLICANT: PAUL D ERICKSEN PHONE: 360-477-9335 or
CINDY S ERICKSEN
92 RUBY RD
PORT ANGELES WA 983629127
SITE ADDRESS: 2682 RAIN FOREST RD Issue Date: 06/13/2013
FORKS, 98331 Final Date:
SUBDIVISION: 9915 Block: Lot: 7
PARCEL NUMBER: 991500007 Section: 30 Township: 27 N Range: 10 W
PROJECT DESCRIPTION: NEW SINGLE-FAMILY RESIDENCE
FLOOD DEVELOPMENT PERMIT
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 Fl • NSPECTION AND RECEIVED FINAL SIGN OFF ON
\\tidemark\data\forms\F_BLD_Occupancy.rpt 7/25/2014
Jefferson County Building vision Permit Niter: BLD13-00121
Applicant: ERICKSEN
BUILDING PERMIT INSPECTION APPROVALS Applicable Code: 2009 International Building Codes
To schedule inspections, call (360)379-4455 no later than 3:00PM the day before the inspection is needed.
Requests received after 3:00 PM will not be scheduled for the next 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 r „2 \3
Erosion Control (�
Foundation Footing r -2b,13 J� o 4.
1
Footing Drains ,5---t3
Foundation Stem Wall
Underground Plumbing 9_se-. 3 ll S t
Under Floor Framing
Straps(hold downs)
Ext. Shear Wall Nailing IO-23- 13
0i
Rough-in Plumbing .3 2 f iY 9
Framing 2, 1 01 9,— RaFru'SnemP5 OIL,
h
Airseal .312_41 )---
Insulation: Walls
Insulation: Floors
cgs12—13 , — R— I o ---(--,L.2i1t t-env,. 2-iv V aRr 1�`6
Insulation: Ceiling 1 I (i(14- n„
-
Int. Shear Wall Nailing Y^
Wallboard Nailing 1 117 I I`i bd
Gas Line: Interior
Gas Line: Exterior
Propane Tank
Heat/Chimney Clearance _.11 ki 11,1
Y
Mechanical Systems
Blower Airtight Test 1 1`I I
ti p
Smoke&CO2 1 I )q
Drywell/Alt Drainage 1 I 1 I ,� 9,-
Address Posted 7 I) I f, "
FINAL INSPECTION • I 11
j1L
FINALp) --
INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
•
CONDITIONS for Building Permit# :BLD13-00121
1.) See BLD13-00120 for Conrev.
2.) A"Construction Drawing" Flood Elevation Certificate was prepared by a licensed surveyor
and submitted with the application. The Certificate identified the base flood elevation of
feet. The lowest floor of the structure is required to be elevated at least one (1) foot
above base flood elevation or feet. PRIOR TO FINAL BUILDING INSPECTION,
PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN ORIGINAL"FINISHED"
CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT HAS BEEN VERIFIED BY
A LAND SURVEYOR, ENGINEER, OR ARCHITECT AUTHORIZED BY LAW TO
CERTIFY ELEVATION INFORMATION IN THE STATE OF WASHINGTON.
3.) New construction and substantial improvement of any residential structure shall have the
lowest floor, including basement, elevated one foot or more above the base flood
elevation (BFE).
4.) 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.
5.) The site plan as submitted with the Building Permit application on April 15, 2013 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 April 22, 2013 shall be resubmitted for review and
approval by Jefferson County Department of Community Development.
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W �'rtry° Lw PAUL CINDY ERICKSEN ENOVIC 8 PORT ANDELES, WA 96362
fFR 09^ 92 RUBY ROAD Z ASSOCIATES PHONE: (360)417-0501
PORT ANGELES, WA 98362 FAx: (360)m-0514
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k��, • C06 JEFFERSON COUNTY -\�
h •
• ��` A� DEPARTMENT OF COMMUNITY DEVELOPMENT I I 1; APR 1 5 2013
' 621 Sheridan Street • Port Townsend • Washington 98368 U LIB
360/379 4451 1
JEFFERSON COUNTY
q`SWING -
N��Q www.co.jefferson.4450wa.us/commdevelopment360/379 Fax __DEPT.OF COMMUNITY DEVELOPMENT
Master Permit Application MLA:
Project Description (include separate sheets as necessary):
- lloh ,Pralnfc
Tax Parcel Number: 991500007 Property Size: /.Z5 (acre /square feet)
Site Address and/or Directions to Property: 2E82 Perin t'rest P.ad, Fork Fork5 WA 98331
Property Owner(s)of Record: MLA l• CM Errcksen
Telephone:360 4-77 •9335 or477•i/.•Fax: email: el-kor-i- C g/mp/i..5.net
Mailing Address: eYic1CSenpc(o/yrnpis•nef; 92 RUby Rci4 art Ar9e.1e5, WA9a562
Applicant/a (if different from owner)): Tracy 3udn e/
Telephone:360 417-0501 Fax:3S0 4t,- 05/4- email: /racy OZPI"ovIC.net-
Mailing Address:30/ Eao- 6+h Otree-, i/llte 0: Ma- Ar e , in/A 9 2
What kind of Permit? (Check each box that applies 0 Lot or Road Segregation
NBuilding ❑Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
EQ Single Family El Garage Attached/ tached -, ❑ Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .❑ Modular . 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)**
D. Change of Use ❑ Boundary Line Adjustment
❑ Address _ ❑ Road Approach 0 Short Plat**
U Home Business ❑ Cottage Industry ❑ Binding Site Plan**
0 Propane ❑ Long Plat**
0 Cign . 0 Planned Rural Residential Development(PRRD)/Amenclments**
❑Allowed"Yes" Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑ Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Substantial Development**
G Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium ❑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 T e3Cy nudge] arrh/1 act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE //)i j, Date: // April 20/-3
By signing this application f ,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 application that he or she wants prior notice.
Signature:
/ Date: // April 70/3
The action or actin 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 resp1nsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ZigfY• yf//r/J) Date: // ril2013
• •
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:
Paul Boynton (.l46).7747 ( )
MAILING ADDRESS: 1/7 Champion Kd. Povt Any les.1✓A EMAIL:
CONTRACTORS LICENSE r� 98362. WAINS
NUMBER: 80YNTG 19520m NUMBER ARCHITECT/ENGINEER: Tracy Gudgel P.E. PHONE (360 417. Gz0I FAX:(36,d `�t
7)7•O5J4
MAILING ADDRESS: .301 E. Sixthdife l Fart Alleles, WA 9�7 EMAIL firaCy0zenovlC.net
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
X New zc Wood Existing: - Sewer
Addition E Steel Proposed: / Bank E Community System
Alteration/Remodel ❑ Concrete Total: I Height: X Individual System
Repair E Masonry — SEP Permit# 5EPI9-00029
C Demolition Other: Bedrooms: Water Supply:
Existing: - Setback: Private well E Two Party
Type of Heat: Proposed: i li Public Wt1nU I
ilitari f heal fi wood Total: / Name of System:
Ea1t r Or ten *t c0445
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
• BC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
i Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other _
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size, distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount . Revision
Main Floor Heated EH Bld App Review: 7p O�
978 7S54o0. OO ,
2nd Floor Heated 460 3$5 , 6 pConsistency Review:/ 0 v
Other Heated Base fee: / /, 2
Mezzanine Additional Section: J
Heated Basement Plan Check fee: ova.
/ JO
Unheated Basement / State Surcharge fee: 7 — —
r
Other Unheated .. Pot Water Review fee: /D/ 0 a
Garage/Carport SUBTOTAL
pt2 Ora3
Decks 911/Rd Approach fee: ^M3—/0
Other front Forth 320 eppe t TOTAL: $ 50-___ ...3,
�� Q�Ileceipt Number: /q o 1 o
� ,,0 1.8" ash/Check Number: 1
,:,03 /U_
t
ESTIMATED COST(REQUIRED) Date: (� Si/2J
.Fair market value of all labor and materials foundation to finish ( � i
Initials: ;1�11
U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE
FEDERAL EMERGENCY MANAGEMENT AGENCY OMB No. 1660-0008
National Flood Insurance Program Important: Read the instructions on pages 1-9. Expiration Date:July 31,2015
SECTION A-PROPERTY INFORMATION FOR INSURANCE COMPANY USE
Al. Building Owner's Name Paul Ericksen Policy Number:
A2. Building Street Address(including Apt., Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number:
2682 Rain Forest Road
City Forks State WA ZIP Code 98331
A3. Property Description(Lot and Block Numbers,Tax Parcel Number, Legal Description,etc.)
Parcel#991500007 Lot 7 Rain Forest Lots(Vol.6 Pg.47-Plats) SE1/4 SE1/4 S.30,T27N R1OW,W.M -'
A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Garage ' -----__! fl V e ____.
A5. Latitude/Longitude: Lat.47-48'-33" Long. 124-02'-09" Horizontal Datum: ❑ NAD 1927 ® NAD 1983 , 7
A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. I.'
A7. Building Diagram Number 1A II �f(JN I,
A8. For a building with a crawlspace or enclosure(s): A9. For a building with art at_a'ched garage: 7 ''r''
a) Square footage of crawlspace or enclosure(s) na sq ft a) Square foots of attached garage na /iq ft
b) Number of permanent flood openings in the crawlspace b) Number of permanent floor openings in the attached garage
or enclosure(s)within 1.0 foot above adjacent grade na within 1.0 foot above adjacent,9'ratle Ot"i1! '-'
c) Total net area of flood openings in A8.b na sq in c) Total net area of flood openings-hi:Al.b'!jrr 1, .. sq in
d) Engineered flood openings? El Yes ® No d) Engineered flood openings? ❑ Yes--- ko
SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION
B1.NFIP Community Name&Community Number B2.County Name B3.State
Unincorp.Jefferson Co.530069-0625-B Jefferson WA
B4.Map/Panel Number B5.Suffix B6.FIRM Index Date B7.FIRM Panel B8.Flood B9. Base Flood Elevation(s)(Zone
625 of 1625 B 7/19/82 Effective/Revised Date Zone(s) AO, use base flood depth)
7/19/82 A Local evidence
B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9.
❑ FIS Profile ❑ FIRM ❑ Community Determined 0 Other/Source:local observation and history
B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑ NAVD 1988 ® Other/Source:assumed elevation
B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? ❑ Yes 0 No
Designation Date: ❑ CBRS ❑ OPA -
SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED)
C1. Building elevations are based on: ❑ Construction Drawings* 0 Building Under Construction* ® Finished Construction
*A new Elevation Certificate will be required when construction of the building is complete. .'"
C2. Elevations-Zones Al-A30,AE,AH,A(with BFE),VE,V1-V30,V(with BFE),AR,AR/A,AR/AE,AR/A1-A30,AR/AH,AR/AO.Complete Items C2.a-h {rlP)
below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters. i
Benchmark Utilized: NW cor.PUD pad Vertical Datum: 100.00'assumed �q
Indicate elevation datum used for the elevations in items a)through h)below. 0 NGVD 1929 0 NAVD 1988 ®Other/Source:assumed
Datum used for building elevations must be the same as that used for the BFE.
Check the measurement used.
a)Top of bottom floor(including basement,crawlspace,or enclosure floor) 100.22 ®feet 0 meters �1
b)Top of the next higher floor n/a. ❑feet ❑meters -
c) Bottom of the lowest horizontal structural member(V Zones only) 100.22 ®feet ❑meters OW'
d)Attached garage(top of slab) n/a. ❑feet ❑meters
e) Lowest elevation of machinery or equipment servicing the building 100.22 ®feet ❑meters
(Describe type of equipment and location in Comments)
f) Lowest adjacent(finished)grade next to building(LAG) 99.60 ®feet ❑meters
g) Highest adjacent(finished)grade next to building(HAG) 100.61 0 feet ❑meters
h) Lowest adjacent grade at lowest elevation of deck or stairs,including structural support na. ®feet ❑meters
SECTION D-SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION IN
This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation k !`�� -I
information./certify that the information on this Certificate represents my best efforts to interpret the data available. t ••�. 4I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. % r
El Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a 5 Q)`,,C �y
® Check here if attachments. licensed land surveyor? ® Yes ElNo r io ?�tS
Certifier's Name Dan P.Kousbaugh License Number RLS#11983 po; 9 fi. 1 a
1S11 - '
Title President Company Name Dan Kousbaugh Surveying Inc,P.S. 6, 'CIS
Address 450 Spruce Drive City Forks State WA ZIP Code 98331 �+4L LANs'
11111
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Signa Date 6/12/14 Telephone (360)374-5720 ` / ':,, ,.
7 r 1 �i l G /L I
FEMA Form 086-0-33( 112) See reverse side for continuation. Replaces . I previous editions.
CLCVAIIVIv VCKIIr•IVNIC, page c
IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O. Route and Box No. Policy Number:
2682 Rain Forest Road
City Forks State WA ZIP Code 98331 Company NAIC Number:
SECTION D—SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION(CONTINUED)
Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner.
Comments On 2/1/13 a benchmark was established on the property at the NW corner of the base pad for the PUD transformer at 100.00'. Two local
property owners were consulted as to their highest observed flood levels in this area. They picked different sites about 500'east-west of each other. Flood
level noted was 91.31'at each site. The original Brandeberry homestead floor level comes in at 92.51'. The 100 year flood level was set at 91.31' The floor
of garage falls at 100.22'.
Signature p, ^,'j 004,(4-tOott04,1Date 6/12/14
SECTION E—rBUI�L`DING ELEVATION INFION(SURVEY NOT REQUIRED)FOR ZONE AO AND ZONE A(WITHOUT BFE)
For Zones AO and A(without BFE),complete Items El—E5. If the Certificate is intended to support a LOMA or LOMR-F request,complete Sections A,B,
and C.For Items El—E4, use natural grade, if available.Check the measurement used. In Puerto Rico only,enter meters.
E1. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent
grade(HAG)and the lowest adjacent grade(LAG).
a)Top of bottom floor(including basement,crawlspace,or enclosure)is 0.39 ®feet 0 meters ❑above or®below the HAG.
b)Top of bottom floor(including basement,crawlspace,or enclosure)is 0.62 ®feet El meters ®above or❑ below the LAG.
E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor
(elevation C2.b in the diagrams)of the building is n/a. ❑feet ❑meters ❑above or El below the HAG.
E3. Attached garage(top of slab)is n/a. ❑feet ❑meters ❑above or ❑below the HAG.
E4. Top of platform of machinery and/or equipment servicing the building is na. ®feet ❑meters 0 above or❑below the HAG.
E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management
ordinance? ®Yes ❑ No ❑ Unknown.The local official must certify this information in Section G.
SECTION F—PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION
The property owner or owner's authorized representative who completes Sections A, B,and E for Zone A(without a FEMA-issued or community-issued BFE)
or Zone AO must sign here.The statements in Sections A,B,and E are correct to the best of my knowledge.
Property Owner's or Owner's Authorized Representative's Name Dan P.Kousbaugh
Address 45 Spruce Drive P City Forks State WA ZIP Code 98331
Signature 7 Date 6/12/14 Telephone (360)374-5720
Comments The floor elevation of the garage is 100.22'whic . well above the estimated 100 year flood level of 91.31'.
®Check here if attachments.
SECTION G—COMMUNITY INFORMATION (OPTIONAL)
The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E),and G
of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8—G10.In Puerto Rico only,enter meters.
GI:1K The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who
is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.)
G2. 0 A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO.
G3.❑ The following information(Items G4—G10)is provided for community floodplain management purposes.
G4. / t Number G G5. at er�d sye 6 !S G6. Date Certificate Of Compliance/Occupancy Issued
Ni - tom l
G7. his permit has been issued for: New Construction 0 Substantial Improvement
G8. Elevation of as-built lowest floor(including basement)of the building: . 0 feet ❑meters Datum .
G9. BFE or(in Zone AO)depth of flooding at the building site: . ❑feet ❑meters Dat
G10.Community's design flood elevation: El feet ❑meters D £. l�/�\\
V
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Local Official's Name Title r/t/,!/ ' /
Community Name Telephone
Signature Date
Comments
❑Check here if attachments.
FEMA Form 086-0-33(7/12) Replaces all previous editions.
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10/15/21112 03:111 PM $72 00 JEFFE7t 1 TITLE go Inc
J•ff�rson Cc+ity Yet fidl[or'• f0 Tiq-Oo. Ejdifri, pyyltor
When recorded return to:
Jefferson County Excise Tax
Paul D.Ericksen and Cindy S.Erickson Alf # 1 8 C to (b 1��0�Z
92 Ruby Road
Port Angeles,WA 98362 Tax S.53 A;n;3
P.y eputy Treasurer
78089-JTc STATUTORY WARRANTY DEED
Escrow No.: 3597
Title Order No.: ' gael
THE GRANTOR(S)
Karen Culver,as her separate estate
for and in consideration of tan dollars and of er good and valuable co ••.•n • d paid,conveys,
and warrants to
Paul D.Ericksen and Cindr S.Ericksen,husband and wife
the following described real estate,situated In the Cou f Je f Washington:
Lot 7 d Rain Forest Lots Division 1,as per Plat ed in V m 6 d Plats,page 47,records
of Jefferson County.Washington
Subject to: Easements recorded under Auditor's File 20 and 375207
Covenants,conditions,restrictions and/or ements under Auditor's File No.254563
Restrictions, conditions, dedications, t , easements and provisions contained and/or
delineated on the face of the Plat record der ditor's Fife No.254585
Loss or damage by reason that there appears rded right of access b and from the
land herein described to a public right of
Tax Parcel Number(s): 991500007 O
Culver
STATE OF WASHINGT
`COUNTY OF • )ss
I certify that I know or Ali evidence that Karen Culver is the person who appeared before
me,and said pe at the signed this instrument and acknowledged it to be her free
and voluntary act for nd purposes mentioned in this instrument
Dated: 1(:)f
TERESA I.WAY
Notary Public
State of Washington
NotaryP ic' the stat W 'ngton My Commission Expires
Reaidin May 15,2016
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Topo USA®6.0
Ericksen Exhibit Map
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Highest observed flood=91.31'in this area
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Proposed Ericksen Homesite
Brandeberry Homestead Floor Elev.=92.51' X Ground Elev. 98.58'to 100.09'
RANDEBERRY RD
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H-1000
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®2006 DeLorme.Topo USA®6.0.
www.delorme.com
ELEVATION CERTIFICATE, page 3 Building Photographs
See Instructions for Item A6.
IMPORTANT: In these spaces, copy the corresponding information from Section A. FOR INSURANCE COMPANY USE
Building Street Address(including Apt., Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number:
2682 Rain Forest Road
City Forks State WA ZIP Code 98331 Company NAIC Number:
If using the Elevation Certificate to obtain NFIP flood insurance, affix at least 2 building photographs below according to the instructions
for Item A6. Identify all photographs with date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side
View." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as
indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page.
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FEMA Form 086-0-33 (7/12)
..,-..,,,.u„ ,,revious editions.