HomeMy WebLinkAboutBLD2006-00266 0251
Ilt
R
ILDING PERMIT APP ML y e:
LICATI Revviewiew Type: i
pe. I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00266 Received Date: 5/17/2006
SITE ADDRESS: 3111 PARADISE BAY RD
PORT LUDLOW, 98365
OWNER: DENNIS D CANADA PHONE: 360-437-7510
LUCINDA J CANADA
3111 PARADISE BAY RD
PORT LUDLOW WA 983659736 TALA SHORES#1
SUBDIVISION: Block: Lot: 5+
PARCEL NUMBER: 998200105 Section: 22 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOl REMODEL EXIST HOUSE W/ ADD 67sq ft HTD SPACE & ADD 335sq ft
DECK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 19
VALUATION 180,000.00 ADD'L: HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: 48 HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY:
CONST TYPE: 5N OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK: 164
DECK: 335 BANK HEIGHT: 40
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: 5 Exist: 4
Prop: -1 Prop: 0
Total: 4 Total: 4
Routing Date /�J/06
b
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $1,441.75 LYK 05/17/06 81231
Plan Check $937.14 LYK 05/17/06 81231 A H e V ED
State Building Code $4.50 LYK 05/17/06 81231 C` ,p
2006
Total: $2,383.39T
Jefferson County Planning
& Building Department
s"" r��c DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
Tel:360.379.4450 Fax:360.379.4451
Web:www.co.jefferson.wa.us/communitydevelopment
95w!N -\o E-mail:dcdna,co.jefferson.wa.us
CERTIFICATE OF OCCUPANCY
PERMIT#: BLD06-00266
APPLICANT: DENNIS & LUCINDA CANADA PHONE: 360-437-7910
D & L CANADA LIVING TRUST AG
3111 PARADISE BAY RD
PORT LUDLOW WA 98365-9736
SITE ADDRESS: 3111 PARADISE BAY RD Issue Date: 10/16/2006
PORT LUDLOW, 98365 Final Date: 8/7/2017
SUBDIVISION: 9982 -TALA SHORES Block: Lot:
PARCEL NUMBER: 998200105 Section: 22 Township: 28 N Range: 1E
PROJECT DESCRIPTION: REMODEL EXIST HOUSE W/ADD 67sq ft HTD SPACE &ADD 335sq ft
DECK
THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003
EDITION.
OCCUPANCY GROUP: R-3
TYPE OF CONSTRUCTION: 5N
SPRINKLER SYSTEM (Vs
THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 8/7/2017
Acting Building Official,
Patty Charnas
\\tidemark\data\forms\F_BLD_Occupancy.rpt 8/9/2017
•
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD06-00266 Received Date 05/17/2006
SITE ADDRESS: 3111 PARADISE BAY RD Issue Date 10/16/2006
PORT LUDLOW, 98365
APPLICANT: DENNIS D CANADA PHONE: 360-437-7910
LUCINDA J CANADA
3111 PARADISE BAY RD
PORT LUDLOW WA 983659736
SUBDIVISION: TALA SHORES#1 Block: Lot 5+
PARCEL NUMBER: 998200105 Section: 22 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: REMODEL EXIST HOUSE W/ADD 67sq ft HTD SPACE &ADD 335sq
ft DECK
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: %c1A4P rncz= Ok Vol(4
UFFER: A)A
Footing: Ok 5/15/67 P F:fiCk' FWce bit, 4/3c/14 tAt
Foundation: MO 17 �'a?4I= �:�� �'�k �-����(►y Gl.�i��is-c pig. 9
ASE � /� e
Stormwater FINAL Approval 19Rk 6t rnr‘:ac, o r. j�!f' r4{/ �'
Underground Plumbing: OK 7�///d7 t / I
Underground Insulation:
Shear Wall : n.� Or4y9c to -1'1 -c7 Grace—v: lD-2?-5l
Sheathing:
Framing: 3/iz/Dg // tr_r rs F� -•-, /Nr�re�L �:%✓..v .s pefiZ `,r
3
10)
Plumbing: /iz,/d'O / Inc!-A441f3i►ai 0k Jc/ /ph'
Propane Tank/ Lines: ri/A- /Insulation:(&t&a� 4�7//r(� 6K3/I4/dd AP <<D,Y_ 1,iofp (� ¢F 114145 /'
Sheetrock:Ex $ED,t'G pt' 7fliyd71/ 0 4/Z op, /C1/jy A SN1 v ( i�us�+L 6 IC'I6i
Septic Sytem Final Approval MUST be obtained be or fina of structurr°e can be attempted. �W2G,i/S
Road Approach Final Approval: ����'� ~
Zoning Final Approval: !
Final/Occupancy Approval: a< for [! ) NV/7 i
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL RE. IRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a rn. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY -SEE REVERSE
•
SPECIAL CONDITIONS FOR CASE A BLD06-00266
1.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the
Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the
Landslide Hazard Area.
2.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated.
Should buffer disturbance occur during construction, the Unified Development Code
(UDC)Administrator shall require replanting with native vegetation. No alterations shall be
made to the Landslide Hazard Area or its associated buffer without prior authorization by
the UDC Administrator.
3.) Prior to and during approved construction activities, the perimeter of the landslide hazard
area buffer shall be marked with a temporary sign. The sign shall be placed in such a
manner that it can be directly observed from the construction area. The sign shall contain
the following statement: "Landslide Hazard Area and Buffer- Do not Remove or Alter
Existing Vegetation."
4.) All construction activities shall not encroach upon the landslide hazard area buffer. This
includes the storage or preparation of materials.
5.) The applicant shall permanently separate the boundary of the Landslide Hazard Area
Buffer from the remainder of the subject property through installing logs, trees, a hedge
row, or any other prominent physical marking approved by the UDC Administrator.
6.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water
quality degradation. The submitted proposal does not require additional aquifer
protection measures. However, during construction the project shall follow the Best
Management Practices (BMPs) and facility design standards as identified and defined in
the Stormwater Management Manual for the Puget Sound Basin.
7.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
8.) VOLUNTARY MEASURES OF COASTAL&AT RISK SIPZ:
Water conservation measures:
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected from Storm water and roof catchments may be used for watering
lawns and gardens. Unless catchment water has been treated to meet drinking water
standards, there shall be no cross connections allowed between the potable supply and
impounded water.
3. Water withdrawn from wells on each property shall not be used for watering of lawns
and/or gardens.
4. Ground water withdrawn from each property shall be restricted to a rate of three (3)
gallons per minute.
5. Installation of water conserving fixtures such as low flow toilets, faucets and shower
restrictors and other water saving plumbing fixtures.
6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation).
Please NOTE that the above listed measures are not intended to be exhaustive, but rather
is intended to be illustrative of the types of water conservation measures.
9.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ:
1. Installation of a flow meter.
2. On-going well monitoring for chloride concentration.
3. Submittal of monitoring data to County.
•
10.) MANDATORY MEASURES FOR COASTAL SIPZ:
1. For proof of potable water on a building permit application, applicant must utilize
DOH-approved public water system if available.
2. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water or an individual well may be used as proof of potable water subject to the
following requirement:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
11.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
12.) 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.
13.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements #1 through #12 of the Department of Ecology's Stormwater Management
Manual for Western Washington to control stormwater, erosion and sediment during
construction. BMPs shall address permanent measures to stabilize soil exposed during
construction, and in the design and operation of stormwater and drainage control systems.
14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
15.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any lot less
than one-half acre 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 Unified Development
Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable
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 of the UDC,
and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any
such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area
(ESA).
16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
17.) Minimum setback from Paradise Bay Road right-of-way shall be 20 feet. Minimum side
yard setbacks shall be 5 feet. Minimum setback from shoreline top of bank per revised
site plan dated September 7, 2006 is approximately 90 feet to nearest drainfield line and
approximately 150 feet to the new addition portion of the residence.
18.) 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.
19.) 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.
20.) The building height is not to exceed 35 feet.
21.) Residential developers and individual builders shall be required to preserve shoreline
vegetation and reduce the associated risk of erosion during construction and any future
activity which may impact the stability of the shoreline.
I:\F_BLD_Permit_Buildng.rpt 10/29/19
c-<7 4,1 pL, A) jr/Y' )
•
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative
size of proposed improvements on the site plan.
This proposed project adds 67sf to the existing house. All of which is currently
covered by cement. It will also establish a new drain field and reserve area. It is
proposed to add a geo-thermal heating/cooling system. The existing second story
deck will be replaced and enlarged from 582sf to 917sf.
PERMIT # BLD
0 6 - 0 2 F 6
Existing Conditions Summary JEFFERSON COUNTY DO
2. Describe the existing topography. Indicate contours on the site plan.
The lot slopes from west to east. There is an existing pathway (currently impassable)
from the bank to the beach. Medium bank waterfront on the Hood Canal.
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
The lot has native unmanicured vegetation from the top of the bank to the beach.
Along the south, west, and parts of the north are native and non-native blackberries,
evergreen huckleberry, azaleas, cotoneasters, salal, rhododendrons, manzanita,
camellias, salmonberry, lily of the valley. The trees on the property include fir,
cedar, hemlock, madrone, maple, alder, and pine. There are six fruit trees on the
north side. The center of the lot is "lawn"or mostly weeds and dandelions.
4. Describe the existing soils. Indicate soil type on the site map.
Rocky soil, clay. See septic engineer report.
5. Describe the existing site hydrology(i.e. drainage; behavior of water on the site-
above, below, and on the ground). Indicate existing storm water drainage to from the
site on the site map. Depict separate drainage basins the site map, if applicable, and
indicate acreage of each.
All water is dispersed on the lot.
6. Describe any excess levels of noise generated by the proposed use or activity.
None.
7. Describe significant geographic and critical areas (i.e. environmentally sensitive
Areas such as wetlands, streams, steep slopes, etc.) on the site. Indicate location on
the site plan. APPROVED
Waterfront property on the Hood Canal.
STORMWATER PLAN
StorrrWater OCT 1 2 2006
Require
JEFFERSONU
DEPT.OF C IT M.144,
SIGNATURE:
.)
• •
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.).
Residential area on Paradise Bay and south of Tala Shores. Sixty foot double bank
to Hood Canal.
Permanent Storm water Control Plan
This portion of the Storm water Site Plan consists of the installation of the appropriate
Storm water control BMP's and facilities to remain in place after construction of the
Project is completed.
"Medium" size project are required to have the total calculated of all impervious
surfaces, pollution-generated impervious surfaces,and pollution-generated pervious
surfaces to verify that the thresholds for treatment facilities and flow control facilities
are not exceeded.
9. Describe the developed site hydrology, are proposed, Indicate whether storm water
Will be fully dispersed (i.e. per BMP T5.30 in the manual)or, if not, what types of
strormwater 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.
All water will be dispersed on the property. The cement patios in front and
back will be replaced with permeable and semi-permeable landscape.
10. If the project requires the use of storm water treatment facilities, describe the types of
storm water treatment facilities proposed for use on the site. Locate these facilities
proposed for use on the site plan and differentiate proposed facilities from existing
facilities. (This is normally for"large"projects or projects that involve for dispersion
of contaminants.
N/A
11. Describe the performance goals and standards applicable to the project.
To improve dispersement of rainwater by unclogging and repairing existing gutters
and drains. Generally clean up the property.
12. Describe the flow control system.
N/A
• •
13. Describe the water quality system.
All construction debris will be contained and properly disposed. All septic and geo-
thermal work will be done by licensed and bonded contractors. We will be on site
during these projects.
14. Describe the conveyance system analysis and design.
N/A
15. Describe the source of fill material,physical characteristics of fill material, and
deposition of excess material.
N/A
16. Proposed methods of placement and compaction consistent with applicable standards
on Appendix Chapter 33 of the Uniform Building Code.
All work on the septic will be done by licensed and bonded contractors.
17. Describe the proposed surfacing material.
Mulch, rock walls, shrubs and plants, lawn and gravel.
18. Describe methods for restoration of the site.
Mulch,reseed lawn and plantings.
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 treated runoff.) If included, list the
Manuals here.
N/A
20. List here and include any special reports or studies conducted to prepare the
Stormwater Site Report.
Septic engineer's report. Attached.
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 here.
• •
Septic redesign. (in progress)
SECTION 1 —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 BMP's 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 section 2.5.2 of the manual (beginning on page 2-15).
12 Required Elements- Construction SWPPP
1. Mark Clearing Limits
No Change.
2. Establish Construction Access.
Current driveway.
3. Control Flow Rates.
N/A
4. Install Sediment Controls
N/A
5. Stabilize Soils.
Berms, if needed, during septic and geo thermal construction.
6. Protect Slopes
N/A
7. Protect Drain Inlets—N/A
8. Stabilize Channels and Outlets
N/A
9. Control Pollutants.
Removal of any drain field material will be done by a licensed toxic waste
removal company.
• •
10. Control De-Watering(the act of pumping groundwater or
storm water away from an active construction site).
N/A
11. Maintain Best Management Practices (BMP's)
I or my husband, Dennis Canada, will be on site and discuss BMP's
with each contractor before the start of each section of the project.
12. Manage Project.
Dennis and I will be the project managers. BMP's will be part of the
bidding process for all contracted work.
2. Adjacent Areas
a. Description of adjacent areas that may be affected by site disturbance.
(e.g. streams, lakes,wetlands, residential areas, roads).
Hood Canal is more than 100' from any work being done on the site.
b. Description of the downstream drainage path leading from the site to
receiving body of water(minimum distance 400 yards).
N/A
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to
the site.
Hood Canal
b. Description of special requirements for working in or near
environmentally sensitive areas.
N/A
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).
N/A
i jt._ a
5. Construction Phasing. ..
• •
a. Construction sequence
Septic system. Deck and north east section. Heating system. Windows,
doors, siding. Upstairs.
b. Construction phasing (if proposed)
Septic. Lower level and decks. Heating system. Upper Level.
6. Construction Schedule. Wet season is October 1 through April 30 (page
2-21 Of the Manual).
Begin as soon as permits are finalized. Work as weather permits and
contractors are available over the next 2 or more years.
a. Provide a proposed construction schedule.
As weather, contractors and materials permit.
b. Wet Season Construction Activities
i. Proposed wet season construction activities.
Possibly septic system and weather permitting outdoor
projects and indoor projects.
ii. Proposed wet season construction activities for
environmentally sensitive areas.
N/A
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or
other financial securities. Dennis Canada and Lucinda(Cindy) Canada
b. Describe bonds and/or other evidence of financial responsibility for
liability associated with erosion and sedimentation impacts.
Personal responsibility of property owners.
8. Engineering Calculations. Provide Design Calculations on a separate sheet
for the following, if applicable.
• •
a. Sediment Ponds/Traps N/A
b. Diversions. N/A
c. Waterways. N/A
d. Runoff/Storm water Detention Calculations N/A
• •
ki,,V.S�N cO O . JEFFERSON COUNTY
W ' q DEPARTMENT OF COMMUNITY DEVELOPMENT
~' 14 621 Sheridan Street • Port Townsend •Washington 98368 MAY 1 7 2006
360/379-4450 • 360/379-4451 Fax
.qSO� www.co.jefferson.wa.us/commdevelopment J
FIIN
.,LVELOPMENT i.
Master Permit Application MLA: O(�, -S
Project Description (include separate sheets as necessary): _ ,
E tE PIzO4LC-T DGSc- iP-I f'l. , ATTkC'Aie,D -c. A:,"c �, ,1�1,'i1 ;.
Tax Parcel Number: `1 t) %Z�'�„-,`� Property
Size: C;0/ .91 926/C) (acres/square feet)
Site Address and/or Directions to Property: `)]i FA ADI5 G. l3A` ROAD l ( i T j.. )D1 OJi`�A 6
Property Owner(s)of Record: ll&NN t i , CINI)Y ANi) STACY C NADA
Telephone:( ,O ) A-'?:,i-- 7 0 I 0 Fax: email:
Mailing Address: '�)I I t A(ADi E ? -1 Re^D, fj R r L C> ,\_u; . A} 51 ?2.G.S.i
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Building ❑ Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
XSingle Family -- R"_*S1odQ_l ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **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 it's knowledge. Any material falsehood or any omission of a material fact made by the oN: f/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.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: . -'' ' r•i.e e(eL.
Date: ; ., j/ ::5•4 4.-t.'(,,
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: , ;f l: ':-'. V*j)4 Date: . //r
G:\PermitCenter\FORMS\DRD FORMS\Master Permit A..lication 12-30-05.doc
• •
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: ye E r.r'L. (1��L.,r "c •., Date: I( }t i'
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
1
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New D. Wood Existing: _ 0 Sewer
X Addition LI Steel Proposed: /Z�J t Bank Height: 1 1 Community System
X Alteration/Remodel ❑ Concrete Total: y.. AO FT X Individual System EXI S T i IIIG
0 Repair 0Masonry SEP Permit# c5 J_ it,..
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: .. Setback: [I Private well ❑ Two Party
Type of Heat: Proposed: _ i 64} Er LI Public
F• ,, _ Total: Name of System:
PRK
TP OF
If this is a Commercial Project you must answer the following: i C' 5 (5 �' SI 1051/4
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 Tank and/or Appliance Installation permit,mark all items below that apply:
i 1 Underground Tank ti Above ground Tank Size of Propane Tank:
[I Heat Stove 11 Cook Stove [I Woodstove I l Fireplace Insert [I Hot Water Tank ❑ Pellet Stove 11 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 u, :', :,Amount Revision
Main Floor Heated I .33 i iv 1l rp oL " EH Bld App Review: /S2 ---
o ` � l
2ntl Floor Heated NA 1,\A c Consistency Review: ( -
Other Heated IAA 13f Base fee: 441 , 15—
J ,
Mezzanine N 4 cQ Additional Section: ,_________
Heated Basement 1835 3-/g i 41
.a . Plan Check fee: G t 3rf . 11
Unheated Basement 4 6 U State Surcharge fee: l
50
...Ad.
Other Unheated Pot Water Review fee:
Exi-i-tnc> ---
Garage/Carport SUBTOTAL Ot
Decks 2 i
58 1 , 91]/Rd"Approach fee: T-
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Other � �.Ap'.1(4 TOTAL: $ a,(4 d 361
II r�l Receipt Nu er: 2143
Cash/Check Number: 4 l h
ESTIMATED COST(REQUIRED) ~� a:1 7 2006I kn 1°ip
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Nair market value of all labor and materials founds On to finish �� i —
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