HomeMy WebLinkAboutBLD2009-00127MIL
IIIBUILDING PERMIT APPLICON MLA09-00137
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00127 Received Date: 4/23/2009
SITE ADDRESS: 132 FOUR CORNERS RD
PORT TOWNSEND, 98368
OWNER: DAVID A HEROUX PHONE: 360-379-1323
MELODY J HEROUX
131 4 CORNERS RD
PORT TOWNSEND WA 98368-9367
SUBDIVISION:
Block: Lot: T 12+
PARCEL NUMBER: 001333040 Section: 33 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NSFR W/ ATT GARAGE & A/G 250 GAL PROP TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,405
VALUATION 258,427.00 ADD'L: 855 HEAT TYPE: PRO
CODE EDITION: 2006 HEAT BASE: HEAT TYPE: RAD
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER: SHORELINE:
CONST TYPE: 5N GARAGE: 445 SETBACK:
CONST TYPE: DECK: 601 BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: OTHER
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 3 Prop: 3
Total: 3 �
IRout�nq Date�9
Type Amo Date: Receipt: Approved/Date Permit $1,884.15 LYK 04/23/09 108290 APPROVED
Plan Check $1,225.09 LYK 04/23/09 108290
State Building Code $4.50 LYK 04/23/09 108290 JUN 1 2009
Potable Water Application $62.00 LYK 04/23/09 108290 Jefferson County Planning
Total: $3,175.74 &Building Department
Jefferson County Building l sion Permit Number: BLD09-00127
Applicant: HEROUX
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2006 International Building Codes
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 L r:C]sf Minimum setback from Four Corners Road right-of-way shall be 20
foet. Minimum side and roar yard setbacks shall bo 5 foot. If an ESA is
present,then the more stricter setbacks shall apply.
Erosion Control SEE CONDITION 2
Foundation Fo G ,‘„..0 - 0
Footing Drains
Foundation Stem Wall
Underground Plumbing 25,)?
Under-Floes—Framing
Straps(hold downs) /L
Ext. Shear Wall Nailing 2
Rough-in Plumbing -7-tb `a •
Framing 7--/D
^t(1
Airseal 7)7 10
Insulation:Walls
Insulation: Floors —1)q 1 Q
Insulation: Ceiling l V
Int. Shear Wall Nailing /c/ _0 �� pt-/3
Wallboard Nailing (0 0 /3_0 1ZA�.>
Gas Line: Interior
11—1— l0
Gas Line: Exterior II-1-to jY
Propane Tank
Heat/Chimney Clearance
Drywell/Alt Drainage SEE CONDITION 1
Address Posted 5- l'/13 2
Sec Lund +7) Q121
FINAL INSPECTION f 9/
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD09-00127
1.) DESIGN CRITERIA FOR SPLASHBLOCKS:
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 MOBIL HOME MUST BE REMOVED FROM THE PROPERTY PRIOR
TO FINAL SIGN OFF r.K.)
4.) 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 single family residence.
5.) An additional setback of five (5) feet is required from the edge of the stream buffer area to
the proposed single family residence.
6.) 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.
7.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or
every one hundred (100) feet, whichever is less. Signs shall be in place prior to and
during construction activities. The signs shall contain the following statement: "Buffer- Do
Not Remove or Alter Existing Vegetation."
8.) A Stormwater Site Plan has be bmitted and approved by the Department
Community Development. Once e 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.
9.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
10.) 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.
11.) A minimum of two (2) on-site parking spaces shall be provided for the single family
residence.
12.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
13.) The building height is not to exceed 35 feet.
14.) Minimum setback from Four Corners Road right-of-way shall be 20 feet. Minimum side
and rear yard setbacks shall be 5 feet. If an ESA is present, then the more stricter
setbacks shall apply.
15.) 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.
16.) 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.
O'S DEPARTMENT OF COMMUNITY DEVELOPMENT
2� 621 Sheridan Street,Port Townsend,WA 98368
1 Tel: 360.379.4450 I Pax:360.3 i 9.4451
4 Web:www.co.jefferson.wa.us/communitydevelopmcnt
E-mail: dcd@co.jeffcrson.wa.us
-4S•f�f N�'ti0'
CERTIFICATE OF OCCUPANCY
PERMIT #: BLD09-00127
APPLICANT: DAVID A HEROUX PHONE: 360-379-1323
MELODY J HEROUX
132 4 CORNERS RD
PORT TOWNSEND WA 98368-9367
SITE ADDRESS: 132 FOUR CORNERS RD Issue Date: 06/4/2009
PORT TOWNSEND, 98368 Final Date: 6/19/2015
SUBDIVISION: Block: Lot: T 12+
PARCEL NUMBER: 001333040 Section: 33 Township: 30 N Range: 1W
PROJECT DESCRIPTION: NSFR W/ATT GARAGE & A/G 250 GAL PROP TANK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2006
EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM yes n
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 6/19/2015
1\tidemark\data\forms\F BLD_Occupancy.rpt 6/25/2015
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C ON cad JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT APR Z 3 2009
621 Sheridan Street • Port Townsend •Washington 98368
0� 360/379-4450 • 360/379-4451 Fax
iNG http://www.co.jefferson.wa.us/commdevelopmentl
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# 09- 13 ] PROJECT/APPLICANT NAME: ZSb+l NO0.,1 1Itu x.1 'a1;1 i
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indica location on the site map.
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8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads, and sensitive/critical areas
(streams,wetlands, lakes, steep slopes,etc.).
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
"Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
a Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual) or, if not, what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. „r. ,
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10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for"large"projects or projects that involve the potential for dispersion of contaminants.]
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11. Describe the performance goals'—and standards applicable to the project.
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13. Describe the water quality system. _ i�y
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14. Describe the conveyance e system analysis and design. APA 2 3 1OUY
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15. Describe the source of fill material, physical characteristics of fill material, and depositi n of excess material.
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16. Proposed methods of.placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
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17. Describe the proposed surfacing material. _
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18. Describe methods lor restoration of the sit
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
large" projects only and only those for which facilities are required to control flow or treat runoff] If included,list the Manuals
here.
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20. List here and include S any special reports r studies conducted t prepare the Stormwater Site Plan.
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21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements, describe those conditions or
restrictions heFe, h./ 51 S f rn ryl -I U.
stormwater she plan template—rev.10121/2008 7
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CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN (SWPPP)
The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the
template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for
preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater
Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential
development.
SECTION I—CONSTRUCTION SWPPP NARRATIVE
1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or
will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable
to the proposal,justify in writing. Descriptions of the 12 Elements are found at Volume II Section 3.2.3 of the Manual (beginning
on page 3-7).
12 Required Elements—Construction SWPPP
1. Mark Clearing Limits.
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2. Establish Construction Access. '.
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3. Control Flow Rates. N I a
4. Install Se.diment Controls.
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5. Stabiliae,Solis.
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6. Protect Slop sr t
7. Protect Drain Inlets.
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stormwater site plan template—rev.10/21/2008
•
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12 Required Elements–Construction SWPPP(continued)
8. Stabilize Channels and Outlets.
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9. Control Pollutants.
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10. ConV,De-Watering (the act of pumping groundwater or stormwater away from an active construction site). .
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11. Maintain Best Management Practices(BMPs).
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12. Manage the Project.
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2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas, roads). 1 -
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b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards). '
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3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or
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site plan template—rev.1D/21/2008 9
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b. Description of special requirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility,settleability, permeability,depth,texture, soil structure).
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5. Construction Phasing.
a. Construction equen e
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b. Construction phasing(if propos-d)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule. I pij.M,b(.ft,9.-YUW
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II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
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b. Proposed wet season construction activities for environmentally sensitive areas.
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7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
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b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts. t�
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8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable.
a. Sediment Ponds/Traps.
b. Diversions.
c. Waterways.
d. Runoff/Stormwater Detention Calculations
storrnweter site plan template—rev.10/21/2008 10
• •
SECTION II—EROSION AND SEDIMENT CONTROL PLAN
Sediment and erosion control measures may be depicted on the master land use application plot plan, a stormwater site plan,and/or a
separate Construction SWPPP site plan. This is a checklist to ensure that the following are depicted on a site plan:
1. General.
a. Vicinity Map
b. Jefferson County Approval Block
c. Erosion and Sediment Control Notes
2. Site Plan.
a. Legal description of subject property.
b. North arrow.
c. Indicate boundaries of existing vegetation(e.g.,tree lines, pasture areas, etc.).
d. Identify and label areas of potential erosion problems.
e. Identify FEMA base flood boundaries and Shoreline Management boundaries(if applicable).
f. Show existing and proposed contours.
g. Indicate drainage basins and direction of flow for individual drainage areas.
h. Label final grade contours and identify developed condition drainage basins. APR 2 3 2009 _-
i. Delineate areas that are to be cleared and graded.
j. Show all cut and fill slopes indicating top and bottom of slope catch lines. ,
3. Conveyance Systems.
a. Designate locations for swales, interceptor trenches,or ditches.
b. Show all temporary and permanent drainage pipes,ditches, or cut-off trenches required for erosion&sediment control.
c. Provide minimum slope and cover for all temporary pipes or call out pipe inverts.
d. Shows grades, dimensions, and direction of flow in all ditches, swales, culverts and pipes.
e. Provide details for bypassing off-site runoff around disturbed areas.
f. Indicate locations and outlets of any dewatering systems.
4. Location of Detention Best Management Practices(BMPs). Identify location of detention BMPs.
5. Erosion and Sediment Control Facilities.
a. Show the locations of sediment trap(s), pond(s), pipes and structures.
b. Dimension pond berm widths and inside and outside pond slopes.
c. Indicate the trap/pond storage required and the depth, length,and width dimensions.
d. Provide typical section views through pond and outlet structure.
e. Provide typical details of gravel cone and standpipe, and/or other filtering devices.
f. Detail stabilization techniques for outlet/inlet.
g. Detail control/restrictor device location and details.
h. Specify mulch and/or recommended cover of berms and slopes.
i. Provide rock specifications and detail for rock check dam(s), if applicable.
j. Specify spacing for rock check dams as required.
k. Provide front and side sections of typical rock check dams.
I. Indicate the locations and provide details and specifications for silt fabric.
m. Locate the construction entrance and provide a detail.
6. Detailed Drawings. Any structural practices used that are not referenced in the Ecology Manual should be explained and
illustrated with detailed drawings.
7. Other Pollutant BMPs. Indicate on the site plan the locations of BMPs to be used for the control of pollutants other than
sediment(e.g., concrete wash water).
8. Monitoring Locations. Indicate on the site plan the water quality sampling locations to be used for monitoring water quality on
the construction site. Sampling stations should be located upstream and downstream of the project site.
starmvrater site plan template—rev.10/21/2008 ij
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Stormwater Site Plan Changes
If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan, the proposed revisions shall be
submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised
drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change.
Final Corrected Plan Submittal
If the project included construction of conveyance systems, treatment facilities,flow control facilities, or structural source control BMPs
(not standard on-site stormwater management BMPs), the applicant shall submit a final corrected plan ("as-builts")when the project is
completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as
constructed.
APPLICANT SIGNATURE
By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and
correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all
owners of the affected property.
t�,, � -P �I - 20 -b9
(LANDOWNER OR A THORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
stormwater site plan template—rev.10/21/2008 12
ON t^ • III
4,--- o JEFFERSON COUNTY
4 ,i DEPARTMENT OF COMMUNITY DEVELOPMENT
ork 621 Sheridan Street• Port Townsend •Washington 98368
4o 360/379-4450 • 360/379-4451 Fax
„q Gip www.co.jefferson.wa..us/commdevelopment -
Master Permit Application APR 2 3 2009 MLA: 09- l
Project Description (include separate sheets as necessary):
O&-- 2-C4-1)(‘)) .- hem L bnS uc.fi u.,
Tax Parcel Number: 001 331, 040 Property Size: 51 ti_ acr square feet)
Site Address and/or Directions to Property: l old Co,ci c(x4-
\32 G)y-rsis eJ. cwt 49-r l I yw J CL)glcuy r I94-i 'c ets sr ' gas -,
Property Owner(s)of Record: 1)c v\A + ■.(--1/48,1( \-- ¢mu x
Telephone: 3( o 3101--15n he J(g) 3140'Fax: Vt.08-4t. email: i t1V MI 3 tr(SO rei%1muA- Loi-
Mailing Address: 131414.--(u+txiesvB 7-524 ceLL
Applicant/Agent(if different from owner): w` R 4 3�` a-�n,..L,
Telephone: Fax: email:
Mailing Address: •
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation
IPBuilding ❑Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor,Major or Reasonable Economic Use)
'$Single Family ❑Garage Attached/Detached ❑Conditional Use(C(a),C(d),or C]"
❑ Manufactured Home .❑ Modular - ❑Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)"*
❑ Change of Use ❑Boundary Line Adjustment
❑ Address ❑Road Approach ❑Short Plat**
❑ Home Business ❑Cottage Industry ❑ Binding Site Plan**
Propane ❑ Long Plat**
❑Sign - ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes" Use Consistency Analysis ❑Plat Vacation/Alteration**
❑Stornwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development**
❑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 ❑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
/eview and any required later inspections. Staff's access and right of entry will be assumed unless the applicant informs the County in writing at the
t time of the application that or s e want nor notice.
d*� Signature: L ' '-\` Date: 4— z 0 -09
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: '�-0�---� Date: Li 1A -69
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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 respons bility of the General Contractor for the proposed project t.
Signature: Date: ` -)-v -09
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAx:
OWY -r L C ✓ (0) 311-132.3 ( )
MAILING ADDRESS: - EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAx:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New , Wood Existing: 0 Viaei ❑ Sewer
❑ Addition ❑ Steel Proposed: 2,c Bank ❑ Community System
Total: 2 Hei t:
❑ Alteration/Remodel ❑ Concrete �I] � Individual System
❑ Repair ❑ Masonry fY SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: I.) Setback: ❑. Private well ❑ Two Party
Ty!, of Heat: Proposed: 16 Public
1; tI IA?3k Total: 3 Name of System:- P 1)
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Ta stallation permit,mark all items below that apply:
1 Underground Tank I Above ground Tank Size of••••-•- -nk: a.ADA
I Heat Stove I Cook Stove W s ove Fireplace Insert Hot Water Tank. Pellet Stove I Other
Is this appliance being installed in a Manufactured/Mobile Home -es 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 properly lines,buildings and septic system components,
includin• the reserve area.
S•uare Foota•e Current Pro••sod °'c 34'4,'1-r-'-
;k r . , uc,, ,�z» ';' :1:..!el ,t ,-;,`' , - 1:
�>L •s 1�.. . ..
Main Floor Heated EH BId App Review: ��
I �I y323q
el Floor Heated g55 ` �)(07 ® Consistency Review:
Other Heated 'vr fi, ` Base fee: ) t!
-it,, 13$1-{ : 15
Mezzanine a Additional Section:
Heated Basement ' ''- :: Plan Check fee: �1 Q
Unheated Basement £ a= ' «��.� 1
,,.�F= , r' State Surcharge fee:. S°
Other Unheated Pot Water Review fee: 00
Garage/Carport i, 4c SUBTOTAL Iq • .�LI
s-t`'4 1 .1" `t•
Decks 1(p 1 r` 911/Rd Approach fee:
X131'2
Other TOTAL: $ •••i• , ft-
�o rc h 41/44O lei 20 `�
N Receipt Number: O$ •L.
P Cash/Check Number:. - -
1 1054 '
ESTIMATED COST(REQUIRED) $cia 7 iv to:
.Fair market value of all labor and materials fou •a'=• •finish Imo_
4 256 t(ro0 Initials: rr MI
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