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HomeMy WebLinkAboutBLD2013-00152 • 1 • BUILDING PERMIT • Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD13-00152 Received Date: 5/16/2013 SITE ADDRESS: 1099 OIL CITY RD Issue Date 10/30/2013 FORKS, 98331 Expiration Date 10/30/2014 OWNER: OSCAR TUAZON PHONE: 323-533-6666 DOROTHEE PERRET 2339 SILVER RIDGE AVE LOS ANGELES CA 90039 SUBDIVISION: Block: Lot: PARCEL NUMBER: 612041008 Section: 4 Township: 26 N Range: 12 W CONTRACTOR: OWNER/BUILDER PHONE: PROJECT DESCRIPTION: RAINWATER CATCHMENT FOR POTABLE WATER FLOOD DEVELOPMENT PERMIT TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION 25,000.00 MAIN: CODE EDITION: 2009 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: 176 GARAGE: SHORELINE CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: 1 CATCHMNT Type Amount Paid By: Date: Receipt: BEDROOMS: BATHROOMS: Permit $391.25 ZAL 05/16/13 142094 Exist: Exist: Plan Check $254.31 ZAL 05/16/13 142094 Prop: Prop: State Building Code $4.50 ZAL 05/16/13 142094 Total: Total: Potable Water Application $66.00 ZAL 05/16/13 142094 Potable Water Application $159.00 ZAL 05/16/13 142094 Potable Water Application $67.00 MEB 10/30/13 145506 Total: $942.06 Directions to Site: HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. Request must be received by 3pm the day before the inspection is needed. Office Hours 9:00 am -4:30 pm MONDAY - THURSDAY HOT LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY-SEE ATTATCHED IUILDING PERMIT APPLICA!JN BLD13-00152 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD13-00152 Received Date: 5/16/2013 SITE ADDRESS: 1099 OIL CITY RD FORKS, 98331 OWNER: OSCAR TUAZON PHONE: 323-533-6666 DOROTHEE PERRET 2339 SILVER RIDGr AVE LOS ANGELES CA 90039 SUBDIVISION: Block: Lot: PARCEL NUMBER: 612041008 Section: 4 Township: 26 N Range: 12 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: JOHN HANSEN PHONE: 360-316-1060 1231 V ST PORT TOWNSEND WA 98368 PROJECT DESCRIPTION RAINWATER CATCHMENT FOR POTABLE WATER FLOOD DEVELOPMENT PERMIT TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 25,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2009 OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OTHER: CONST TYPE: GARAGE: 176 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: 7 V/3 Type Amount Paid By: Date: Receipt: Approved/Date Permit $391.25 ZAL 05/16/13 142094 Plan Check $254.31 ZAL 05/16/13 142094 APPROVED State Building Code $4.50 ZAL 05/16/13 142094 Potable Water Application $66.00 ZAL 05/16/13 142094 OCT 3 0 2013 Potable Water Application $159.00 ZAL 05/16/13 142094 Total: $875.06 Jefferson County DCD \\firJomorlr\rInfn\forme\F RI fl 4Inn PIA rnf F/1 C.r7l11'3 III• • 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 wit be assumin res b of the Ge ral Contractor for the proposed project Signature Date -_ Siu. e I S • '3 GENERAL CONTRACTOR OR MANUFACTURED Hove INSTALLER: P.iONE• Fax: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE ——WAINS NUMNER: NUMBER ARCHITECT/ENGINEER: —` —._— PHONE ( ) FAX:( ) MAILING ADDRESS. — EMAIL Type: -- Type: --- -- -- -Project Frame Bathrooms: Shoreline: Type of Sewage Disposal: ri New 0 Wood Existing: 11 Sewer G Addition ❑ Steel Proposed Bank 0 Community System ❑ Alteration/Remodel 0 Concrete Total: Height: )Q lndividuai S tern G Repair 0 Masonry SEP Permit# �T�[v- ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing Setback: i Private well Two Party Type of Heat: Proposed I • Public Total' Name of System: If this Is a Commercial Project you must answer the following: - Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: fOp° P cy: IBC Type of construction Will you have Food Service? Yes /_N� If this is a Propane Tank and/or Appliance Installation permit,mark all Items below that apply: 1 Underground Tank ! Above ground Tank Size of Propane Tank: i Heat Stove i Cook Stove 1 Woodstove 1 Fireplace Insert Hot Water Tank i Pellet Stove 1 Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property Ltines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage - t1 Current Proposed For Qfiit:b a1�. Amouctt. .. -- - Main Floor Heated � EH Bid App Review- 2"4 Floor Heated f �-- ,_ . 7?-r v kConsistencyReview ���/ Other Heated - j Base fee Mezzanine -• __ - Additional Section: Heated Basement - —--1- Plan Check fee: �.c ei- 3 / Unheated Basement . , State Surcharge fee' L( Other Unheated Pot Water Review fee: /Sg, 00 - t.r a .v J pt cs i b►-t -Garage/Carport — =- /046. o0 SUBTOTAL a o la � peed 6 17] �' - 1_1/Rd Approach fee: Other A' IkJ^7TE - __- / `U �( TOTAL: $ 0 ( , OIL E G -r-r Receipt Number: qo, ?o! ell S\191— J ;x Cash/Check Number 3ry Q�i -... .. . ESTIMATED COST(REQUIRED) l T t/Q Date: S D 7 'Farr +�e bbor end materials foundation to finish ! // / _�_-- lam L/ Initials: C::\PermircenreArrm/FGRMS#r!#1Dkti FORMS\master Permit Applinuon 5-2 -OS d t N �� Cod JEF ON COUNTY e MAY 1 ` 4 DEPARTMENT OF COMMUNITY DEVELOPMENT 6 2013 _iP EUEt11 VE =' 621 Shendan Street•Port Townsend •Washington 98368 \,� 360/379-4450 • 360/379-4451 Fax \9.p�NasO$ www co.jefferson.wa.us/commdevelopment DEPI OF COMMSON COUNTY �� JNITY DEV ElO�MENT Master Permit Application Project Description(includ arate sheets s neces a MLA: PefOrt LE Tax Parcel Number: Property Size: G (acres/square feet) ( Site Address and/or Directions to Property: v i 9 (2'(1 C( MP / V''RKS Property Ovine s of Record: C, CAE. ;' Telephone: 3 Fax. A email: 5 l @lDvcay idabzoh,Cc5 Mailing Address: �3 rt ?� 1 J U 7 V Applicant/Agent if different from owner): 40110144 N s Cat Q{c)3� Telephone: - C ��J[c`�7�--IV Fax: email Q•• ®Lnr9iu Mailing Address:_ - yI Ey.e 0C What kind of Permit?(Check each box that applies — 0Building U Demolition Permit O Critical Areas Stewardship Plan ❑Single Family ❑Garage Attached/Detached O❑Variance(Minor, Major or Reasonable Economic Use) Conditional Use(C(a),C(d),or CI•• ❑ Manufactured Home 0 Modular 0❑ Commercial• Discretionary.D"or Unnamed Use Classification El Change of Use 0 Special Use(Essential Public Facilities)** ❑ Address ❑Road Approach ❑Boundary Line Adjustment ❑Home Business ❑Short Site " ❑Propane i Cottage Indust CI Binding Site Plan"• ❑Sign DLong Plat" 0 Planned Rural Residential Development(PRRDyAmendments•" ❑Allowed`Yes'Use Consistency Analysis Cf Stormwater Management Cl Plat Vacation/ARerabon'• SPAAD 0 Shoreline Master Program Exemption/Permit Revisions•" ❑Site Plan Approval Advance Determination ❑Temporary Use (SPAAD) 0 Shoreline Management Substantial Development" Wireless Telecommunication• 11 Shoreline Management Variance Forest Practices Act/Release of Six-Year Moratorium 0 Comprehensive Plan/UDC/Land Use District Map Amendment •May require a Pre-Application Conference ❑Jefferon County Shoreline Master Program Amendment s _____ required Vegetation Request Please identify any other local,state or federal permits "'Requires a Pro Applica on Conference for this proposal,if known: I hereby designate �� D SIGNATION OF AGENT to act as my agent in matters relating to this application for OWNER SIGNATURE Date: 0 S l•' PeRnit(s)' • I(. I l By signing this application form,the owner/agent attests that the information provided herein,and in any attachments, his,her or Is knowledge. Any material falsehood or any omission of a material fact made by the owner/agentith re true and correct to the bestk of may result in this permit being null and voidsped to this application packet I further agree to save,indemnity and hold harmless Jefferson County against aft 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 nght of entry to Jefferson County and Rs employees,representatives or agents for the sole purpose W review and any required later inspections taffs access and right of entry will be assumed unless the applicant informs the County in wntingg at the on time of the appl t he t Signature: __ Date: O r. 1 r .. 1 7 The action or actions pplicant will undertake as a result of the issuance of this r endangered species and could lead to a potential'take'of an endangeredpermit may negatively are impact in theh one or more known the 'Endangered Species Act or"ESA.'Jefferson County makes no ass ncess to tthheas those terms are definedhe actions is federaleundertaken w knn because permit has been issued will not violate the ESA. Any individual,group or agency can le a lawsuitt ton behalf of an endt will angered this action(s)even if you are in compliance with the Jefferson County development code The Applicant ackn species rs individual y yourl and non-trans i a owtedges that he,she or it holds individual Signature: oo+*iplYing vurth the ESA The Applicant has read this d sCla rand signs and dates t below Date. 0 - I - t 3 ( Prrmite..rnra\rr##FORMS###\Dill)FT..W 1/Amer Pamir APPlic3lva 5-29-08dcK • • • CONDITIONS for Building Permit# :BED13-00152 1.) 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. 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 5-7 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" \R. 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.) Construction Materials and Methods of Construction to Reduce Flood Hazard (i)All new construction and substantial improvements shall be constructed with materials and utility equipment resistant to flood damage. (ii)All new construction and substantial improvements shall be constructed using methods and practices that minimize flood damage. (iii) Electrical, heating, ventilation, plumbing, and air-conditioning equipment and other service facilities shall be designed and/or otherwise elevated or located so as to prevent water from entering or accumulating within the components during conditions of flooding. Locating such equipment below the base flood elevation may cause annual flood insurance premiums to be increased. 4.) 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). 5.) The site plan as submitted with the Building Permit application on May 16, 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 May 28, 2013 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 6.) Prior to Final Occupancy the water catchment system must be inspected by a certified American Rainfall Catchment Association (ARCSA) accredited professional and documentation sent to the Health Department that the system was installed as designed and will function as proposed. 7.) Prior to final occupancy a satisfactory bacteriological water sample result must be submitted to the Health Department taken from a faucet within the household, that confirms the water catchment system and treatment is providing potable water. 8.) Notice to title was recorded for potable water under AFN \\tidemark\data\forms\F RI fl Pprmit Rlrin rot lmnof113 Jcf#erson County Building L,ivision Permit Niter: BLD13-00152 Applicant: TUAZON 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 1-27-I Foundation Footing _ 0 _Z? I`t Rough-in Plumbing I �7_ I`f Mechanical Systems4 FINAL INSPECTION ;12,1 17 n FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING EING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR "pp Front Parcel Review • Parcel 612041008 Printed: May 28, 2013 OSCAR TUAZON Site Address: DOROTHEE PERRET 1099 OIL CITY RD 2339 SILVER RIDGE AVE LOS ANGELES, CA 90039 FORKS WA, 98331 Parcel ��------ Number: 612041008 S-T-R: 4-26N-12W Total Acreage 5 ) Legal Description S4 T26 R12W TAX 6 Land Use: 1100 Flood District: Fire District: 0 Planning Area: 12 Flood Map (FIRM) Panel No: School District 402 Zoning: COMP PLAN DESIGNATION: COMMUNITY PLAN: UGA: UGA Trans [ ii]" Plot plan states "property line" [ tf Assessor's Map (Property lines on bmitted plot plan must match the property lines as identified on the Assessor's 1/4 map) [ L] Legal Access to Property NO [c.,K Parcel Tags or Scanned Documents YES NO [ tyL ESA's: Special Reports Nearby YES NO [l/ Designated Ag YES 0 [ Shoreline Designatio ASP NO Co( ZU iCf [ ] Shoreline Slo•- ability: YES NO it �r Stream Ty s; O or - `7 -_ Fish & Wildli 40 NO "2 7 a a . � Wetlands: YES 0 Rare Plants:YES NO Seismic: YES NO Landslide: YES NO Flood: c'YES) NO - T (ooc9 Cps Erosion: YES NO Aquifer Recharge Are lip NO 5 .4- SIPZ: none At Risk -_ High RisskCoastal CMZ: none High Risk Moderate RiskDisconnected CMZ Stormwater site plan submitted: YesNo [ F,],— Forest Lands: YES Adjoining Forest Lands: Commercial/ Rural/ Inholding [ Mineral Lands: YES [ v]' Agricultural Lands: YES [ (4' Archaeology: YES Stormwater: New Impervious Surface ( /Land Disturbing Activity ESA's Stormwater Req's:Min Req#2 Min Req#1 thru#5 Min Req#1 thru#10 Engineering [Vi Notice Provisions/Disclosure:A''sort YES NO MRL YES NO Forest Lands YES NO [ (/( Landscaping Required: Yes a [ v( Parking Spaces R-- -d ►O 2 Other f Building Height: c. UBC Standard [ 7 Impervious Surface coverage percentage: Resource Lands& Public: 1040 Rural Residential: 25% Rural Induip: Per UDC Sec 6.7 Rural Commercial: 60% Area of Building Coverage: 60%in Rural Ind al Lands only [ e;-] Total Building (s) Size: RVC:20,000 SF CC: 5,000 SF NC: 7,500 SF GC: 10,000 SF All others:subject toptic&water constraints/None specified [ 14 Setbacks: Front: 2./0 Left Side: Right Side: 17 Rear: .> Shoreline Setback: LSHA Setback: ' [ t Road Classification: Road Approach: EXISTIN NOT REQ'D RAP [LA"- SEPA Required: YES EXEMPT [ Flood Certificate: [ V]' Existing Case(s) & Condition(s): Violations: Yes No [ Vr Recorded Date of Subdivision: AFN Over 5yrs=UDC Plat Conditions: <5yrs=Plat Conditions on plat or Old Ordinance [IX Lots/Require Declaration of Restrictiv ovenant YESsubmitted: YES NO [fj)' UGA No Protest Agreement YES ubmitted: YES NO [ Site Visit conducted YES [ Vr Require Final Zoning Approval YES O [ (/]' ADMIN: Setbacks entered in Permit Plan case 0011 YES New Parcel Tags entered in Permit Plan ► • YES Special Reports Scanned 91a'ES No parcel tags found for parcel Cases Associated with APN 612041008 Cases Name Review Type Status Planner BLD13-00152 TUAZON p Application Received: 5/16/2013 Permit Issued/Case closed: Case Finaled: RAINWATER CATCHMENT I-OR POTABLE WATER FLOOD DEVELOPMENT PERMIT M LA01-00158 BLD01-00199 MLA01-00158 PEDERSEN I F M FARFAN Application Received: 4/6/2001 Permit Issued/Case closed: 6/18/2001 Case Finaled: 8/9/2002 GARAGE/SHOP CAR00-00305 PEDERSEN F K RUSSELL Application Received: 7/6/2000 Permit Issued/Case closed: 8/29/2000 Case Finaled: 8/29/2000 conventional trench PRJ00-00159 PEDERSEN p Application Received: 7/14/2000 Permit Issued/Case closed: Case Finaled: SEP00-00165 PEDERSEN Application Received: 7/6/2000 Permit Issued/Case closed: 9/12/2003 Case Finaled: USR00-00073 PEDERSEN F Application Received: 9/18/2000 Permit Issued/Case closed: 1/14/2002 Case Finaled: 2 dry holes on this site. no well bearing water(LAM) \\tidemark\data\forms\R_Parcel_CRMLA.rpt 5/28/2013 Page 2 of 2 ...., ... ..- ... . . um . . um uft ur uJ l.r Lair WU illii Lit iril tali iii/ 664 a, W l WI C N Z r N O .. rn z0 Iel rn � rnxDO CA -+ Dz c\T4 riimit) ,_, .0. f_ mr,, , cf) Z D D O-I cn cn Z �4? ` o ›` rn � � (� O m 1 m • N _ r Z� mx0 � ~ m N rn b -1 IV r; O z D7 `4 0 n 7 =a. � O X _< _. * r- > o m 0m o 0- > • go O N z r W I D ♦lir ♦10 ♦gb• ♦fit ♦me ♦lb• ♦ib• ♦10 ♦1 • ♦10 ♦lb••♦Ib• ♦I ♦ cam n.. 0 ,irel.w`otrew,g6 7.1..1%now%7•1,11-76,,‘Z.•;..-17:7t-ITZT36•70:71:17:71;11-- :74134:4 ' CD CD 1 N r 444.1 . tZlkt° � N 7) R- 27 .V -E. /4 ' zD -I -i C � = m C i D :00:sl _ _ _ _ _ _ _ _ _ _ _ O co C n Z A Z O• 0 m z O 1041•:•• { CnD rn ♦� ♦�� - 4., �i V� ♦ ♦� • CDO m m • 0 Oc) m o O7:3 TT •� �♦�•4�0. •41 • i • X 0XD -I ♦ ♦ ♦ ♦W• lb,�♦ ♦ \< _ TT eX �046• %♦ %• •W%• � _ T4 ( Rom ��� � ♦� ♦��►♦b ♦b ��, —1 o mz mDrn ` :•! .!� .ti,e;, N, • z m� �..�♦. ♦.� 0 z m xi (0 - I ;O � %� I W m mcn 00 00 T ,,•�.��� Q CJ) _ _ - m 0 u m > C D n CO m X O 4 � r C � 5 � m - C = D i, Z73 1\ 0 �J 0 * i.- -I mm0 II ti G) D � Omin O O -!'i � DT O W. D • SO � N � I- co _, 0 N —I Inn OH 73 = rnCn O Cm > __ 'Jill_ �� � ,� � C � r � y_ / 0 rn C J O > � � � � z w N ) .,.. rn CO .� - C -ID Z -0Do _n^ r 1 > Z � -< 0 ` • O _ , Z Z Zi W z W -A 73 :U G) D m 0 Z 2 C p0 m o _ > 70 Z m q Fri o / N O rn r 1 o) r N rn0m rri-1 —I 0 ---T- rn 0 -_-1 0 -I 73 - Dc _ OW i Zbw r 73 c --1.0.0.__)1 /7J -� � mm0m � * �•,.1 � m D n � � rn J 0 c � l - 1- mrno 0 Q � � � v0� _ rn D co i r_ 0 \/ Z _ pvOD O m • _1 Zm �j - po0 Cm DZ nD ODC =gy m= Z o o ,CD -i* 0 ' om c z -1 3J mm CO z w o x o O s • I 4���°N ���� JEFFERSON COUNTY ;i r� r Imo, _ , DEPARTMENT OF COMMUNITY DEVELOPMENT ' 7 L � — v -� I, -N s..,.? 10 fre---'-.:-:..... 621 Sheridan Street • Port Townsend • Washington 98368 i f.', ;, I LL!i3 O 360/379-4450 • 360/379-4451 Fax �`�$INO� http://www.co.jefferson.wa.us/commdevelopment/ 1 JEFFERSON COUNTY __ _DFPT_OF COMMUNITY DEVELOPMENT Stormwater Calculation Worksheet MLA# PROJECT/APPLICANT NAME: DETERMINING STORMWATER MANAGEMENT REQUIREMENTS: This stormwater calculation worksheet should be completed first to classify the proposal as "small,""medium," or"large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE (I.E.,SITE) Size of parcel acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover (both vegetative and non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling, excavation, and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir,western hemlock,western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry, and salal; herbaceous plants such as sword fern, foam flower, and fireweed. LAND DISTURBING ACTIVITY, CONVERSION OF NATIVE VEGETATION, AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Construction site for structures L Does the project convert 3 acres or more of .7& sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank, etc. sq/ft Circle: Yes No Well, utilities, etc. sq/ft Does the project convert 2 1/z acres or more of native vegetation to pasture? Driveway, parking, roads, etc. sq/ft Circle: Yes No Lawn, landscaping, etc. sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 1.16 sq/ft Cut Fill (cu/yd) [over] stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 1 I • Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops, walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen materials, and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. STORMWATER CALULATIONS—IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area) 116' sq/ft Structures (all roof area) I45-D sq/ft Sidewalks sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc sq/ft Driveway, parking, roads, etc / go` sq/ft Other sq/ft Other sq/ft Total New I 110 _sq/ft Total Existing 4'76 7 sq/ft TOTAL NEW+TOTAL EXISTING* q`l 7 sq/ft *This amount will be used BY STAFF to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: cyo Does the site have 35%or more of existing impervious surface? Circle: Yes No FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of"medium" projects—those that must meet only Minimum Requirements #1 through #5—and for "large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation 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 owner .f th affected pri perty. A _1, ., , _ J - f3 (LAN0• RORAUTHORZEIREPRESENTATIVESIGNATURE) ( ATE) FOR •FFICE USE ONLY SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 2 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 Oscar Tuazon Policy Number: A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg. No.)or P.O.Route and Box No. Company NAIC Number: 1099 Oil City Road(Cougar Glen Road-Hoh River) City Forks State WA ZIP Code 98331 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Lot 10 Vol. 10 Pg. 143-Surveys; Parcel#612041008; Por.Gvt. Lt.6 Sec.4,T26N,RI2W,W.M.Jef.Co A4. Building Use(e.g., Residential,Non-Residential,Addition,Accessory,etc.) Rainwater Harvesting Tank Pad A5. Latitude/Longitude:Lat.47 deg.47.346' Long. 124 deg.15.854' Horizontal Datum: El NAD 1927 ® NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawispace or enclosure(s) NA sq ft a) Square footage of attached garage NA sq ft b) Number of permanent flood openings in the crawispace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade NA within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b NA sq in c) Total net area of flood openings in A9.b NA sq in d) Engineered flood openings? ❑ Yes ® No d) Engineered flood openings? El Yes Z No SECTION B-FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1.NFIP Community Name&Community Number B2.County Name B3. State Unincorporated Jef.Co.530069 0575 575 Jefferson Washington B4.Map/Panel Number B5.Suffix B6. FIRM Index Date B7. FIRM Panel B8. Flood B9 Base Flood Elevation(s)(Zone 530069 0575 B 7/19/82 Effective/Revised Date Zone(s) AO,use base flood depth) 7/19/82 A 159.4'-164.9" B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9. ❑ FIS Profile ❑ FIRM ❑ Community Determined Z Other/Source:WSDOT by Herrera E.C.7/04 B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ® NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? El Yes ® No Designation Date: ❑ CBRS ❑ OPA SECTION C-BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) C1. Building elevations are based on: ® Construction Drawings' ❑ 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 below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters. Benchmark Utilized:Y-473-1974 Vertical Datum: 186.95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h)below. ❑ NGVD 1929 El NAVD 1988 0 Other/Source: 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) NA. ❑feet ❑meters b) Top of the next higher floor NA. ❑feet ❑meters c) Bottom of the lowest horizontal structural member(V Zones only) NA. ❑feet ❑meters d)Attached garage(top of slab) NA. ❑feet ❑meters e) Lowest elevation of machinery or equipment servicing the building NA. ❑feet El meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) **169.74 ®feet ❑meters g) Highest adjacent(finished)grade next to building(HAG) "171.16 ®feet El 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 This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation 1 �. information.I certify that the information on this Certificate represents my best efforts to interpret the data available. <'.. ............... I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. El y;i (' Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a • ryx , %ty CI ® r • 3 Check here if attachments. licensed land surveyor? Yes ❑ No 1 'c. I -3 rF Certifier's Name Dan P. Kousbaugh License Number RLS 11983 Title President Company Name Dan Kousbaugh Surveying, Inc.,P.S. dzsi• � Address 450 Spruce Drive City Forks State WA ZIP Code 98331 Signature --`a pi,iyajhuete 5/23/13 Telephone (360)374-5720 C/Z3/i3 ELEVATION CERTIFICATE, page 2 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: 1099 Oil City Road(Cougar Glen Road-Hoh River 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 **Denotes undisturbed ground elevations in area where base pad will be constructed for potable rainwater harvesting system. 100 year flood elevations were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70,#80&#90 the 100 year flood level was set at 159.4', 160.7', 162.0'and 164.9'respectively. Undisturbed ground levels range from 169.74'to 171.16'where the concrete base pad will be set.Signature n� Date 5/23/13 SECTION E—BUILDING ELEVATION INFORMATION(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. El. 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 NA. ❑feet El meters ❑above or❑below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is NA._ ❑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 NA. ❑feet ❑meters El above or ❑below the HAG. E3. Attached garage(top of slab)is NA. ❑feet ❑meters ❑above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is NA. ❑feet ❑meters ❑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 450 Spruce Drive City City Forks State WA ZIP Code 98331 Signature a ,1 � Date 5/23/13 Telephone (360)374-5720 Comments Flooror of existing home at this site 171. and base pad area 169.74'-171.16'is above 100 year flood level of 159.4'to 164.9'. ❑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. G1. ❑ 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. ❑ 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.Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building: ❑feet ❑meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10. Community's design flood elevation: ❑feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. 0' 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 Oscar Tuazon Policy Number: A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Company NAIC Number: 1099 Oil City Road(Cougar Glen Road-Hoh River) City Forks State WA ZIP Code 98331 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Lot 10 Vol.10 Pg.143-Surveys; Parcel#612041008;Por.Gvt.Lt.6 Sec.4,T26N,R12W,W.M.Jef.Co A4. Building Use(e.g.,Residential,Non-Residential,Addition,Accessory,etc.)Rainwater Harvesting Tank Pad A5. Latitude/Longitude.Lat.47 deg.47.346' Long.124 deg.15.854 Horizontal Datum: ❑ NAD 1927 ® NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) NA sq ft a) Square footage of attached garage NA sq ft b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade NA within 1.0 foot above adjacent grade NA c) Total net area of flood openings in A8.b NA sq in c) Total net area of flood openings in A9.b NA sq in d) Engineered flood openings? 0 Yes ® No d) Engineered flood openings? ❑ Yes El No SECTION B—FLOOD INSURANCE RATE MAP(FIRM)INFORMATION Bt.NFIP Community Name&Community Number B2.County Name B3.State Unincorporated Jef.Co.530069 0575 575 Jefferson Washington B4.Map/Panel Number B5_Suffix B6.FIRM Index Date B7.FIRM Panel B8.Flood B9 Base Flood Elevation(s)(Zone 530069 0575 B 7/19/82 Effective/Revised Date Zone(s) AO,use base flood depth) 7/19/82 A 159.4.-164.9" B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9. ❑ FIS Profile ❑ FIRM ❑ Community Determined ® Other/Source:WSDOT by Herrera E.C.7/04 B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ® NAVD 1988 ❑ Other/Source: _ B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 0 Yes ® No Designation Date: ❑ CBRS ❑ OPA SECTION C—BUILDING ELEVATION INFORMATION(SURVEY REQUIRED) Cl. Building elevations are based on: ® Construction Drawings' 0 Building Under Construction' 0 Finished Construction 'A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1—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 below according to the building diagram specified in Item A7.In Puerto Rico only,enter meters. Benchmark Utilized:Y-473-1974 Vertical Datum: 186,95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h)below. NGVD 1929 ®NAVD 1988 0 Other/Source 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) NA. 0 feet 0 meters b)Top of the next higher floor NA. 0 feet 0 meters c) Bottom of the lowest horizontal structural member(V Zones only) NA. _ 0 feet 0 meters d)Attached garage(top of slab) NA. ❑feet 0 meters e) Lowest elevation of machinery or equipment servicing the building NA. 0 feet 0 meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) "169 74 ®feet ❑meters g) Highest adjacent(finished)grade next to building(HAG) "171.16 ®feet 0 meters h) Lowest adjacent grade at lowest elevation of deck or stairs,including structural support NA. 0 feet 0 meters SECTION D—SURVEYOR,ENGINEER,OR ARCHITECT CERTIFICATION r This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation r information./certify that the information on this Certificate represents my best efforts to interpret the data available. `l •' "" •::: I understand that any false statement may be punishable by fine or imprisonment under 18 U.S.Code,Section 1001. ' "'`' ;•.' , j ® Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a j 0 Check here if attachments. licensed land surveyor'? ® Yes 0 No ) Certifiers Name Dan P.Kousbaugh License Number R LS 11983 S,�, '` T,^11.�J pit:'./4 j4 Title President Company Name Dan Kousbaugh Surveying,Inc.,P.S. di5.�'y='I f �•`� Address 450DA/ Spruce Drive City Forks State WA ZIP Code 98331 SAL L'1 s Signature �} /� 4, ate 5/23/13 Telephone (360)374-5720 ,�Y ,cfl �yf�1J�1 ` • t YI, !/�lv,/......l(:J/.J M10 r 6723/13 ELEVATION CERTIFICATE,page 2 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: 1099 Oil City Road(Cougar Glen Road-Hoh River 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 "Denotes undisturbed ground elevations in area where base pad will be constructed for potable rainwater harvesting system. 100 year flood elevations were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70,#80&#90 the 100 year flood level was set at 159.4',160.7',162.0'and 164.9'respectively. Undisturbed ground levels range from 169.74'to 171.16'where the concrete base pad will be set. /� Signature j /J 7F ► (7 Date 5/23/13 SECTION E—BUILDING ELEVATION INFORMATION(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. El. 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 NA. 0 feet ❑meters ❑above or❑below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is NA. 0 feet 0 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 NA.__ 0 feet 0 meters ❑above or 0 below the HAG. E3. Attached garage(top of slab)is NA. ❑feet ❑meters ❑above or 0 below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is NA. 0 feet 0 meters 0 above or 0 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 0 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 450 Spruce Drive City Forks State WA ZIP Code 98331 • Signature Date 5123/13 Telephone (360)374-5720 'Comments Floor of existing home at this site 171. and base pad area 169.74'-171.16'is above 100 year flood level of 159.4'to 164.9'. ❑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. G1.❑ 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.❑ 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.Permit Number G5. Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑New Construction ❑Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building: ❑feet 0 meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10.Community's design flood elevation: 0 feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. Fi---„ _________________i o:r v ui \ ) U.S. DEPARTMENT OF HOMELAND SECURITY \ OMB No. 1660-0008 Federal Emergency Management Agency 2 7 201e 1 Expiration Date: November 30, 2018 National Flood Insurance Program )FC iI ELEVATIONSLE. TIfi E Important: Follow the instrLct)oh§b $4 hi'page . { f FrT.r . - Copy all pages of this Elevation Certificate and all attachment's-fa(1)community official, (2)insurance agent/company, and (3)building owner. SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Policy Number: Oscar Tuazon A2. Building Street Address(including Apt., Unit, Suite, and/or Bldg. No.)or P.O. Route and Company NAIC Number Box No. 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Forks Washington 98331 A3. Property Description (Lot and Block Numbers,Tax Parcel Number, Legal Description, etc.) Lot 10 Vol. 10 Pg. 143-Surveys: Parcel#612041008; Portion Gvt. Lt. 6 Sec.4, T26N, R12W,W.M., Jefferson County,WA A4. Building Use(e.g., Residential, Non-Residential, Addition,Accessory, etc.) Rainwater Harvesting Tank Concrete Pad A5. Latitude/Longitude: Lat.47 deg 47.346' Long.124 deg 15.854' Horizontal Datum: ❑ NAD 1927 ❑x NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number NA A8. For a building with a crawlspace or enclosure(s): a) Square footage of crawlspace or enclosure(s) 0 sq ft b) Number of permanent flood openings in the crawlspace or enclosure(s)within 1.0 foot above adjacent grade 0 c) Total net area of flood openings in A8.b 0 sq in d) Engineered flood openings? ❑Yes 0 No A9. For a building with an attached garage: a) Square footage of attached garage 0 sq ft b) Number of permanent flood openings in the attached garage within 1.0 foot above adjacent grade 0 c) Total net area of flood openings in A9.b 0 sq in d) Engineered flood openings? ❑ Yes ❑x No SECTION B—FLOOD INSURANCE RATE MAP(FIRM)INFORMATION B1. NFIP Community Name&Community Number 82. County Name B3. State Unincorp.Jefferson County 530069 0575 B Jefferson Washington (>I B4. Map/Panel B5. Suffix B6. FIRM Index B7. FIRM Panel B8. Flood Zone(s) B9. Base Flood Elevation(s) Number Date Effective/ (Zone AO, use Base Revised Date Flood Depth) "'" 575 of 1625 B 07/19/1982 07/19/1982 A 159.4'- 164.9' 8 B10. Indicate the source of the Base Flood Elevation (BFE)data or base flood depth entered in Item B9: ❑ FIS Profile ❑ FIRM ❑ Community Determined x❑ Other/Source: WSDOT by Herrera E.C. 7/04 C. B11. Indicate elevation datum used for BFE in Item B9: ❑ NGVD 1929 ❑x NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System (GBRS)area or Otherwise Protected Area(OPA)? ❑ Yes ❑x No =-',- Designation Date: ❑ CBRS ❑ OPA FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 1 of 6 ' OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 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: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 SECTION C—BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) C1. Building elevations are based on: ❑ Construction Drawings* ❑ Building Under Construction* x❑ Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1—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 below according to the building diagram specified in Item A7. In Puerto Rico only, enter meters. Benchmark Utilized: Y-473-1974 Vertical Datum: 186.95'NGS-NAVD88 Indicate elevation datum used for the elevations in items a)through h) below. ❑ NGVD 1929 0 NAVD 1988 ❑ Other/Source: 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) 171. 33 x❑ feet ❑ meters b) Top of the next higher floor N/A. 0 feet ❑ meters c) Bottom of the lowest horizontal structural member(V Zones only) N/A. ❑x feet ❑ meters d) Attached garage(top of slab) NSA. 0 feet ❑ meters e) Lowest elevation of machinery or equipment servicing the building 171. 33 x❑ feet ❑ meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished) grade next to building (LAG) 170, 66 0 feet ❑ meters g) Highest adjacent(finished)grade next to building(HAG) 171. 29 0 feet ❑ meters h) Lowest adjacent grade at lowest elevation of deck or stairs, including NSA. x❑ feet ❑ meters structural support SECTION D—SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION This certification is to be signed and sealed by a land surveyor, engineer, or architect authorized by law to certify elevation information. I certify that the information on this Certificate represents my best efforts to interpret the data available. I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code, Section 1001. r Were latitude and longitude in Section A provided by a licensed land surveyor? 0 Yes ❑No 0 Check here if attachments. , Certifier's Name License Number i�a„d,'- «rr° : :""E"1=74 " :_ / Dan P. Kousbaugh RLS 11983 � KCDU,St. N Title ;t r) �';,,y=`y, President Cyr t t r, '�""� i Company Name .� i:.3 �`~4 t 4 Dan Kousbaugh Surveying, Inc., P. S. fy;✓ k': Address i ,•1'' rr st ool 4-�� '} 450 Spruce Drive �4 4J LA�t .w-?' City State ZIP Code J3 Forks Washington 98331 ." , ' Signat re , •' Date Telephone ZC 1(�,, /, 12/13/2016 (360) 374-5720 /` f , LL.7 i,..,„, „.• Copy all pages of this Elevation Certificate and al(attachments for(1)community official, (2)insurance agent/company, and(3)building owner. Comments(including type of equipment and to ation, per C2(e), if applicable) 171.33'is the average elevation taken from 4 shots on the concrete pad established for a potable rainwater harvesting system. 100 year flood levels were determined for WSDOT by Herrera Environmental Consultants in 7/04. In this area covered by cross sections#60,#70 #80 and#90 the 100 year flood levels was set at 159.4', 160.7', 162.0'and 164.9'respectively. As shown above the concrete base pad for the potable rainwater harvesting tank at an elevation of 171.33' is set well above any calculated base flood elevations. FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 2 of 6 i OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 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: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 SECTION E—BUILDING ELEVATION INFORMATION (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. El. 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 04 ❑x feet ❑meters ❑x above or ❑below the HAG. b) Top of bottom floor(including basement, crawlspace, or enclosure)is 0 67 0 feet ❑meters ❑x 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 1-2 of Instructions), the next higher floor(elevation C2.b in the diagrams)of the building is N/A. 0 feet ❑meters ❑above or ❑below the HAG. E3. Attached garage(top of slab) is N/A. ❑x feet ❑meters ❑above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is 0 04 0 feet ❑meters ❑x 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 or Owner's Authorized Representative's Name Dan P. Kousbaugh Address City State ZIP Code 450 Spruce Drive Forks Washington 98331 Signat re 1 / Date Telephone 12/13/2016 (360)374-5720 Coments ( , The concrete pad for the potable rainwater harvestirig system has an average floor elevation of 171.33'. This elevation is above the determined 100 year flood elevations of 159.4', 160.7', 162.0'and 164.9'established by Herrera Environmental Consultants for WSDOT in 7/04. j Check here if attachments. FEMA Form 086-0-33(7/15) Replaces all previous editions. Form Page 3 of 6 OMB No. 1660-0008 ELEVATION CERTIFICATE Expiration Date: November 30, 2018 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: 1099 Oil City Road (Cougar Glen Road-Hoh River) City State ZIP Code Company NAIC Number Forks Washington 98331 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. G1. ❑ 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 ❑ 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. Permit Number G5. Date Permit Issued G6. Date Certificate of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑ Substantial Improvement G8. Elevation of as-built lowest floor(including basement) of the building: ❑ feet Limeters Datum • G9. BFE or(in Zone AO)depth of flooding at the building site: ❑ feet ❑ meters Datum G10. Community's design flood elevation: ❑feet ❑ meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments(including type of equipment and location, per C2(e), if applicable) X❑ Check here if attachments. FEMA Form 086-0-33 (7/15) Replaces all previous editions. Form Page 4 of 6 1 I 1 I \, 1 \------\ 1 \� I W oi \ N.) ) (-,,,. z N N O N co N N 1p 3 3Ag^m O F 3 R g too o _ _O a al aa�s .. 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THE FOUNDATION DESIGN IS BASED ON THE RECOMMENDATION IN E3RA GEOTECHNICAL REPORT # E08050b, DATED JUNE 6, 2008 . FOUNDATION WORK AND SOIL PREPARATION SHALL BE PERFORMED IN ACCORDANCE WITH THIS REPORT. 2. THE FOUNDATION DESIGN IS BASED ON THE FOLLOWING VALUES: ALLOW. SOIL BEARING 1500 PSF SOIL FRICTION .35 EQUIV.-FLUID PRESSURES ACTIVE PRESSURE* 55 PCF PASSIVE PRESSURE 200 PCF CONCRETE CONCRETE1. ALL OTHERWISE NOTED OL CHARACTERISTICS SOF WEIGHT TLESS HARD T ANROCK 0.05TYPE (150 PCF) AGGREGATES SHALL CONFORM TO ASTM C33 WITH PROVEN ARACTER 2. CONCRETE COMPRESSIVE STRENGTHS AT 28 DAYS (f0'c) SHALL BE: SLAB ON GRADE: PSI CONTINUOUS FOOTINGS: 2500 PSI 3. ALL CONCRETE WITH A DESIGNATED COMPRESSIVE STRENGTH- EXCEEDING 2500 PSI SHALL REQUIRE SPECIAL INSPECTION BY AN INSPECTOR APPROVED BY THE BUILDING DEPARTMENT AND THE ENGINEER. 4. CEMENT SHALL CONFORM TO ASTM C150, TYPE I, CSA NORMAL. 5. MAXIMUM SLUMP SHALL NOT EXCEED 4 INCHES IN FLATWORK. 6. PLACEMENT OF CONCRETE SHALL BE IN CONFORMANCE WITH, ACI 301. 7. CONCRETE SHALL BE MAINTAINED IN A MOIST CONDITION FOR A MINIMUM OF FIVE (5) DAYS AFTER PLACEMENT. ALTERNATE METHODS WILL BE APPROVED IF SATISFACTORY PERFORMANCE CAN BE ASSURED. 8. NTS LL BE GHLY AND KEYED LAII CONSTRUCTION BEBE JOINTS EMOVED. B ALLED IN VERTICAL JOINTSS ALL SHALL BETHOROUGHLYHLYI WETTEDAAND SLUSHED WITH ACLEANED COAT OF NEAT CEMENT IMMEDIATELY BEFORE PLACING NEW CONCRETE. 9. POUR JOINTS SHALL BE LOCATED TO MINIMIZE EFFECTS OF SHRINKAGE AS WELL AS PLACED AT POINT: OF LOW STRESS. MAXIMUM AREA OF POUR JOINTS IS 400 SF. 10, MINIMUM CONCRETE COVERAGE OF REINFORCING STEEL FOR FORMED WORK SHALL BE AS FOLLOWS: EXPOSED TO EARTH OR WEATHER (45 OR SMALLER): 1�1h" *NOTE: CONCRETE CAST AGAINST GROUND SHALL HAVE 3" MINIMUM COVERAGE 11. PIPES OTHER THAN ELECTRICAL CONDUITS SHALL NOT BE EMBEDDED IN STRUCTURAL CONCRETE EXCEPT WHERE SPECIFICALLY APPROVED. 12, CONCRETE MIXES SHALL BE PROVIDED IN ACCORDANCE WITH ACI 318 (WHEN STRENGTH DATA FROM TRIAL BATCHES OR FIELD EXPERIENCE ARE NOT AVAILABLE). CEMENT CONTENT SACKS PER LBS/CUBIC YARD CUBIC YARD F'c (PSI) (MINIMUM) (MINIMUM) 2500(no special inspection) 470 5 SEE NOTE A MIXES SHALL BE PROPORTIONED TO PRODUCE A SLUMP OF 5" OR LESS. NO MORE THAN A 1" PLUS TOLERANCE SHALL BE ALLOWED. A) WHERE SPECIAL INSPECTION IS NOT REQUIRED UNDER SECTION 1704.4 OF THE I.B.C., CONCRETE SHALL HAVE A MINIMUM CEMENT CONTENT OF 5 SACKS PER CUBIC YARD OF CONCRETE. B) DESIGN MIX (OTHER THAN AS SPECIFIED IN THIS TABLE) SHALL BE SUBMITTED TO THE BUILDING OFFICIAL TWO WEEKS PRIOR TO FIRST USE. REINFORCING STEEL 1. ALL REINFORCING STEEL SHALL CONFORM TO ASTM A615 GRADE 60 (fy = 60 KSI) FOR BAR SIZES NO, 5 & LARGER, GRADE 40 (fy = 40 KSI) FOR NO. 3 AND NO. 4 BARS. 2. ALL REINFORCING STEEL SHALL BE LAPPED AS NOTED ON THE PLANS. WHERE LAP OR SPLICE LOCATIONS ARE NOT SPECIFICALLY INDICATED ON THE CONSTRUCTION DOCUMENTS, LAPS AND/OR SPLICES SHALL BE 42 BAR DiA AND BE WELL STAGGERED. 3. WELDED WIRE FABRIC SHALL CONFORM TO ASTM A82 AND A185 AND SHALL BE 6X6 W2.9/W2.9 UNLESS OTHERWISE NOTED. LAP REINFORCEMENT 8" MINIMUM. 4. ANCHOR BOLTS, DOWELS AND OTHER EMBEDDED ITEMS SHALL BE SECURELY TIED IN PLACE BEFORE CONCRETE IS POURED. SLAB ON GRADE REINFORCEMENT SHALL BE PLACED AT MID -DEPTH OF SLAB AND SHALL BE HELD SECURELY IN PLACE WITH MECHANICAL DEVICES DURING PLACING OF THE CONCRETE. GENERAL 1. ALL MATERIALS AND WORKMANSHIP SHALL CONFORM TO THE CONTRACT DRAWINGS. 2. DURING THE CONSTRUCTION PERIOD THE CONTRACTOR SHALL BE RESPONSIBLE FOR THE SAFETY OF THE BUILDING. THE CONTRACTOR SHALL PROVIDE ADEQUATE SHORING, BRACING AND GUYS IN ACCORDANCE WITH ALL NATIONAL, STATE AND LOCAL SAFETY ORDINANCES. ANY DEVIATION MUST BE APPROVED PRIOR TO ERECTION. 3. ALL ERECTION PROCEDURES SHALL CONFORM TO OSHA STANDARDS. ANY DEVIATION MUST BE APPROVED BY OSHA PRIOR TO ERECTION. 4. THE CONTRACTOR SHALL BE SOLELY RESPONSIBLE FOR ALL CONSTRUCTION PROCEDURES INCLUDING LAGGING, SHORING AND PROTECTION OF ADJACENT PROPERTY, STRUCTURES, STREETS AND UTILITIES IN ACCORDANCE WITH ALL NATIONAL, STATE AND LOCAL SAFETY ORDINANCES. 5. THE CONTRACTOR SHALL BE RESPONSIBLE FOR COORDINATING THE WORK OF ALL TRADES AND SHALL CHECK ALL DIMENSIONS. ALL DISCREPANCIES SHALL BE CALLED TO THE ATTENTION OF THE ENGINEER AND BE RESOLVED BEFORE PROCEEDING WITH THE WORK. 6. DRAWINGS INDICATE GENERAL AND TYPICAL DETAILS OF CONSTRUCTION. WHERE CONDITIONS ARE NOT SPECIFICALLY INDICATED BUT ARE OF SIMILAR CHARACTER TO DETAILS SHOWN, SIMILAR DETAILS OF CONSTRUCTION SHALL BE USED SUBJECT TO REVIEW BY THE ENGINEER. 7. ALL DETAILS DESIGNATED AS STANDARD OR TYPICAL SHALL OCCUR IN ADDITION TO ANY OTHER SPECIFIC DETAIL CALLED OUT. 8. COORDINATE WITH MECHANICAL, PLUMBING, AND ELECTRICAL DRAWINGS FOR SIZE AND LOCATION OF ALL OPENINGS REQUIRED FOR DUCTS, PIPES, PIPE SLEEVES, ELECTRICAL CONDUITS, AND OTHER ITEMS TO BE EMBEDDED IN CONCRETE OR OTHERWISE INCORPORATED IN STRUCTURAL WORK. 9. PROVIDE OPENINGS AND SUPPORTS, AS REQUIRED PER STANDARD DETAILS FOR HEATERS, MECHANICAL EQUIPMENT, VENTS, DUCTS, PIPING, ETC. ALL SUSPENDED MECHANICAL EQUIPMENT SHALL BE SWAY OR LATERALLY BRACED. 10. ALL INFORMATION SHOWN ON THE DRAWINGS RELATIVE TO EXISTING CONDITIONS IS GIVEN AS THE BEST PRESENT KNOWLEDGE BUT WITHOUT GUARANTEE OF ACCURACY. WHERE ACTUAL CONDITIONS CONFLICT WITH THE DP,AWINGS, THEY SHALL BE REPORTED TO THE ENGINEER SO THAT THE PROPER REVISIONS MAY BE MADE. MODIFICATION TD DETAILS OF CONSTRUCTION SHALL NOT BE MADE WITHOUT PRIOR WRITTEN APPROVAL OF THE ENGINEER. 11. ARCHITECTURAL AND MECHANICAL PLANS ARE CONSIDERED A PART OF THE STRUCTURAL DESIGN DRAWINGS AND ARE TO BE USED TO DEFINE DETAIL CONFIGURATIONS INCLUDING; BUT NOT LIMITED TO RELATIVE LOCATION OF MEMBERS, ELEVATIONS, DIMENSIONS AND LOCATIONS OF ALL OPENINGS, ETC. FOUNDATION PLAN --------------------------- SCALE: 1'=1'-0" - n, . rr X 4 X 7 W/ 3/a' 0 ITH 6 Ys" EMBED.- EPDXY SET-XP ADHESIVE. (SEE 2 / S-1.0) :ES) FOI,....._,.... ,.,..,.��..r�...� 215348 214 0 (V j4 0 12" O.C. EACH WAY 2) #5 CONTINUOUS BARS OP AND BOTTOM AS SHOWN TYP. PERIMETER FOOTING OLE m 0 J 0 00 I 0 W N 0 Z 0 0 215348 i 0 i 00 It O _. 0 An - Pa Z 214404 00 JEFFERSON COUNTY DCD BUILDING PLAN REVIEW BASE PLATE ASSEMBLY PER MFR. APPROVED AS SUBMITTED 2 1 APPROVED AS NOTED ❑ REJECTED Dated Reviewer FILE l. 6 2013 u JEFFERSON COUNTY DFPT OF COMMUNITY DEVELOPMENT E VJ 0 CD CT) O N L0 N L� L Q Q O L L O J O � DO _0 L O O Y Q O �' N �+;0 O oo 0 P.0 N L N L Z O CL z � � Q 00 W U Q Q O Q CDOO O JAN 0 3 2014 Drawn By: CHRIS Checked By: CHRIS Date: 05-07-13 SDA JOB NO. 7036 STRUCTURAL S-1.0