HomeMy WebLinkAboutBLD2005-00412 JILDING PERMIT APPLICATON MRAOWOO Type:
I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00412 Received Date: 6/17/2005
SITE ADDRESS: 9066 FLAGLER RD
NORDLAND, 98358
OWNER: ROBERT W RODDICK PHONE: 360 471-3998
RUTH E RODDICK
2350 S HOWER AVE
PORT ORCHARD WA 98366 OTTERNESS SHORT PLAT
SUBDIVISION: Block: Lot: 2
PARCEL NUMBER: 021204020 Section: 20 Township: 30 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW Pole Bldg MAIN FLOOR UNHEATED n-R. 0 Gk ,
e1A roc to
TYPE OF WORK RES SQUARE FOOTAGE* `�JC,C
TYPE OF IMP NEW c�.C��j.ct
�" ` OGrn
VALUATION 132,102.00 MAIN: UY1� t I
ADD'L: ilu 1,248 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE'. AT TYPE:
OCCUPANCY: R-3 a�°s
OCCUPANCY: UNHEATED: " STORIES: 3
CONST TYPE: 5-1HR OTHER: SHORELINE:
GARA
CONST TYPE: DECKLE ,247-� SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 1 Prop: 2
Total: t Total: 2
Routing Date:
�n1 � /11-
)C
Type Amount Paid By: Date: Receipt: Approved/Date
State Building Code $4.50 RAC 06/17/05 73280 AP P R ov E r
Potable Water Application $53.00 RAC 06/17/05 73280
Plan Check $766.06 RAC 06/17/05 73280 JUL 2 9 2005
Permit $1,178.55 RAC 06/17/05 73280 efferson County Planning
Total: $2,002.11 • & epartment
•
M
eview�ILDING PERMIT APPLICATION R 00384
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00412 Received Date: 6/17/2005
SITE ADDRESS: 9066 FLAGLER RD
NORDLAND, 98358
OWNER: ROBERT W RODDICK PHONE: 360 471-3998
RUTH E RODDICK
746 FIRGLADE CT NW
BREMERTON WA 98311-8992 OTTERNESS SHORT PLAT
SUBDIVISION: Block: Lot: 2+
PARCEL NUMBER: 021204020 Section: 20 Township: 30 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEW Pole Bldg -UNHEATED EXCEPT FOR 235 SQ FT UTILITY ROOM
WITH BATHROOM
REVISION - 2nd Bathroom and deck added back in upstairs.
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,493
VALUATION 79,946.00 ADD'L: 1,248 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: 235 HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES: 3
OCCUPANCY: OTHER:
CONST TYPE: 5-1HR GARAGE: 0 SHORELINE:
CONST TYPE: DECK: 287 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 0 Prop: 2
Total: 0 Total: 2
Routing Date:
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: Bi_D05-00412 Received Date 06/17/2005
SITE ADDRESS: 9066 FLAGLER RD Issue Date 07/29/2005
NORDLAND, 98358
APPLICANT: ROBERT W RODDICK PHONE: 360 471-3998
RUTH E RODDICK
2350 S HOWER AVE
PORT ORCHARD WA 98366
SUBDIVISION: OTTERNESS SHORT PLAT Block: Lot: 2
PARCEL NUMBER: 021204020 Section: 20 Township: 30 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW Pole Bldg -UNHEATED EXCEPT FOR 235 SQ FT UTILITY
ROOM WITH BATHROOM
CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: 1IL.STAKES
UFFER:
Footing: OK 9/23/c,S,
Foundation— .
Stormwater FINAL Approval:
Underground Plumbing: alb
Underground Insulation:
Shear Wall :
Sheathing:
Framing:
Plumbing:
Propane Tank/ Lines: glq-1Ix 1147/67git
Insulation: S'/qh, t?-(tt> 6 S ./2 pi
Sheetrock:
Septic Sytem Final Approval (If not on sewer):
Road Approach Final Approval:
Zoning Final Approval:
Final/Occupancy Approval:
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. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY -SEE REVERSE
��Sc�N �o JEFFERSON COUNTY
H DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street I Port Townsend, WA 98368
4,_ ;+st-> „� 360 379 4450 I email: dcd@co.jefferson.wa.us
ysFfi NCS\°~ www.co.jefferson.wa.us/commdevelopment
BUILDING PERMIT
PERMIT#: BLD05-00412 Received Date: 6/17/2005
SITE ADDRESS: 9066 FLAGLER RD Issue Date 8/19/2016
NORDLAND, 98358 Expiration Date 8/19/2017
OWNER: ROBERT W RODDICK PHONE: 360 471-3998
RUTH E RODDICK
9066 FLAGLER RD
NORDLAND WA 98358
SUBDIVISION:
PARCEL NUMBER: 021204020 Section: 20 Township: 30 N Range: 1 E
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW Pole Bldg -UNHEATED EXCEPT FOR 235 SQ FT UTILITY ROOM WITH
BATHROOM
REVISION - 2nd Bathroom and deck added back in upstairs, 4/1/14
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,493
VALUATION 79,946.00 ADD'L: 1,248 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: 235 HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES: 3
OCCUPANCY:
OTHER:
CONST TYPE: 5-1 HR SHORELINE:
RA
CONST TYPE: pE GE"CK: 280 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL Type Amount Paid By: Date: Receipt:
BEDROOMS: BATHROOMS: Consistency Review- Per I $49.00 RAC 06/17/05 73280
Exist: 0 Exist: 0 State Building Code $4.50 RAC 06/17/05 73280
Prop: 0 Prop: 2 Water Review $34.00 RAC 06/17/05 73280
Total: 0 Total: 2 Potable Water Application $53.00 RAC 06/17/05 73280
Plan Check $766.06 RAC 06/17/05 73280
Permit $1,178.55 RAC 06/17/05 73280
Refund - Permit -$324.80 DWJ 08/05/05 TREAS 7154
Refund - Plan Check -$211.12 DWJ 08/05/05 TREAS 7154
Plan Check $76.00 JLA 07/31/13 142325
EH-Techical Assistance $78.00 JLA 04/01/14 148555
Total: $1,703.19
• •
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.
Final Inspections require 24 hour notice.
Office Hours 9:00 am -4:30 pm MONDAY- THURSDAY
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY- SEE ATTATCHED
Jefferson County Building Division Permit Number: BLD05-00412
Applicant: RODDICK
BUILDING PERMIT INSPECTION APPROVALS Applicable Code: 2003 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 8/26/2005 -+'"'ect"
Post Holes 9/23/2005 0 .r trt-
Post Holes deck only
Underground Plumbing 11/3/2006 l� _r^!5Z-
Straps(hold downs) ei/17
Ext. Shear Wall Nailing //L/// ri
il
Rough-in Plumbing /Ayt‘Framing 4/ ,7 -
Insulation: Floors 6/8 012 l`-1-- Z slab R-10 ins pass 6-8-12 RTB
Gas Line: Exterior 12/14/200714_ ....-"ter--
,fithviv f is -1/ r40/c Cq 411 1/O/— ] /0/ik//G ..tar s �/ pewe/c.�.)L�s E
/� A-- tf lI� Y� /,/�Y/7�rrYt d W 4-1,
I e- w.v^cs �� //D/V4 101
7„,,„j,4.,b.-_, — k-iii c e; I is,j/6."1/s- /
Aec.I — 6 —d4 — I 7 6-•))
A final inspection will not be scheduled until the following are completed and signed off by the applicable Department:
• Building Permit Conditions are met • Septic Permit Final/Complete for any building containing plumbing
• Land Use Conditions met and signed off • Public Works Permit Final(where applicable)
FINAL INSPECTION gill rJ le Pk -�cA---• + Y J
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
• •
CONDITIONS for Building Permit# :BLD05-00412
1.) 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.
2.) 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.
3.) 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.
4.) 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.
5.) 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.
6.) MANDATORY MEASURES FORRAT RISK 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 requirements:
a. Chloride concentration of a laboratory-certified well water sample submitted with
building permit application.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
7.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
8.) A flow meter shall be installed prior to final sign off of the building permit.
9.) On-going well monitoring for chloride concentration is required. The property owner shall
allow access to Jefferson County PUD or approved contractor to take samples as
required.
10.) 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.
11.) A Stormwater Site Plan has been submitted and approved by the Department of
Community Development. Once the 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.
12.) The revised site plan dated June 24, 2005 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 July 8, 2005 shall be resubmitted for review and approval by Jefferson
County Department of Community Development.
13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
14.) 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).
15.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
• •
16.) The building height is not to exceed 35 feet.
17.) Minimum setback from SR 116 right-of-way shall be 30 feet. Minimum setback from
ingress/egress easement rights-of-ways shall be 20 feet. Minimum side and rear yard
setbacks shall be 5 feet.
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.) A minimum of two (2)on-site parking spaces shall be provided for the single family
residence.
21.) MANDATORY MEASURES OF HIGH 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.
22.) MANDATORY MEASURES FOR HIGH RISK 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 requirements:
a. Variance from Chapter 173 WAC standards granted by Ecology per WAC 173-160-
106 for a new groundwater well within 100 feet of a sea-salt water intrusion area per WAC
173-160-171 (i.e., within 100 feet of a groundwater source showing chloride
concentrations above 200mg/L or within 100 feet of the marine shoreline); or for an
existing or proposed groundwater well not subject to an Ecology variance, applicant must
provide evidence through a hydrogeologic assessment(relevant components of an
Aquifer Recharge Area Report per UDC 3.6.10.e)of a reasonable probability that the
subject aquifer will not be degraded by the proposed use of well.
b. Installation of a flow meter.
c. On-going well monitoring for chloride concentration.
d. Submittal of flow and chloride data to the County per monitoring program.
3. If public water is unavailable, a qualifying alternative system may be used as proof of
potable water.
23.) A flow meter shall be installed prior to final sign off of the building permit.
• !
24.) On-going well monitoring for chloride concentration is required. The property owner shall
allow access to Jefferson County PUD or approved contractor to take samples as
required.
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BARN BUILDER
UNCLE HOWARD'S
360 Howanut Road
Oakville, Washington 98568
360-273-7816
,4,' e06, JEFFERSWOUNTY
j -, DEPARTMENT OF COMMUNITY DEVELOPMENT
'' 1-4 621 Sheridan Street• Port Townsend •Washington 98368 1' , r�
k.
, /l 360/379-4450 • 360/379-4451 Fax l �� j
\i'" INO � www.co.jefferson.wa.us/commdevelopment
Master Permit Application LA: 0 -%"3z-
Project�° Description{� (include s@parate sheets as necessary): --- --
p�r,,, .. o_k4 -•,/ki.51-' /—e-ii4 a/-r _
Tax Parcel Property
Number: U,),,j '0 y Cj,.2,0 _ Sizee: , C; I 5 ci (acres/square feet)
/
Site Address and/or Directions to Property: OG( /--/C(c�e�ie't Llo.c+(& m t t i
Property Owner(s)of Record: R � y
Telephone: 3, 6 0 `/7/ '3 iciSS Fax: email:
Mailing Address: 3 5 F--0 S S. /0 iu e A ti e j9 r 1- U r< tict eel t t)A tr7 Sf 3 t
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Building I Variance(Minor,Major or Reasonable Economic Use)
Demolition Permit I Conditional Use[C(a),C(d),or CI**
Ji ngle Family I Discretionary`D"or Unnamed Use Classification
..1 Garage Attached/Detached _J Special Use(Essential Public Facilities)**
▪ Manufactured Home I Boundary Line Adjustment
Modular Short Plat**
• Commercial* _ Binding Site Plan**
Change of Use _i Long Plat**
▪ dress i Road Approach _J Planned Rural Residential Development(PRRD)/Amendments**
E/Propane ; Plat Vacation/Alteration**
J Allowed"Yes"Use Consistency Analysis _, Shoreline Master Program Exemption/Permit Revisions**
Stormwater Management - Shoreline Management Substantial Development**
Site Plan Approval Advance Determination(SPAAD)* 1 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 owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature:ia� e` - Date: to 'i —4)
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-transfer esponsibif rhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature:• d - j/ Date: 4.--/<. c,,-
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc
•
OWNER 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
theywill be assu 'n the r ' '
/a�`� e General Contractor for the proposed project.
Signature: /. r, Date: /5 —C3
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: ` .�- FAX: 4
( ) jUlA A) i �LiJJ.�
i•t
MAILING ADDRESS: EMAIL: i -----
CONTRACTOR'S LICENSE WAINS ____.-------
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) `ll,_Li : -FAX:-(--
F (,; )
MAILING ADDRESS: EMAIL •
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
Vllew .-Wood Existing: i Sewer
Addition L Steel Proposed: -s , I Bank Community System
Alteration/Remodel C Concrete Total: �s2 \ Height: i- Individual System
li Repair I. Masonry SEP Permit#SEtbS---000CS
-! Demolition Other. Bedrooms: Water Supply:
Existing: Setback: We'Private well I Two Party
Type of Heat: Proposed: I Public
Total: Name of System:
/-1etz- p:tri,p
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 Tank andior Appliance Installation permit,mark all items below that apply:
i Underground Tank I ve ground-Tank- Size of Propane Tank: 5 v c, (-,¢
I Heat Stove Cook t i Woodstove i Fireplace Insert(l Hot Water Tan I Pellet Stove i Other /A;t O-'r-
Is this appliance being installed in a Manufactured/Mobile Homes? -Yes fl
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 For Office UsqOnly
Current Pro sec 351 LQb•0 Amount
Main Floor ,, ^ 3.� / nsistency Review:
2 Floor wr � tJ 4 "
ND se fee D I CA•
goer `'"'\` � lag bti,`�`i 'l4t•��o l I y 6J/R55:15
• Additional Section: I
im.,..4,0 No gl T - / 'it' / YAcbG.l to
Mezzanine: Plan Check fee: a/1• ]a ri Utt.:;. C(0/55-1•94
Heated Basement, �� `, •ol!State Surcharge fee: C
t.k\. •� roe try 4.J
Unheated Basement Pot Water Review fee: C�
. Uy�
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ESTIMATED COST(REQUIRED) _ _ Date: / l�
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$ 621 Sheridan Street• Port Townsend•Washington 983 J L , .;;, 1,1 cy
1 ( p 360/379-4450-360/379-4451 Fax )8 _: _ 1... �` 'v'' 7
HUNG http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# 0 ) 354 PROJECT/APPLICANT NAME: ROlp eft w �-R�a R J A ,Adt<
Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the
applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a
separate stormwater site plan map.
Project Overview
1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the
site map.
V ,-e-Arei I Cr Iv- s o.1 ‘,..A...M. cp., C‘.4 r�yo . G Nt ram. (.1f-
eo Ll barn r.;t, -� o. oCk,, of -be c.r-cO, - c-(�. '.� as A•43•41
o►1 S c!. iervl .
Existing Conditions Summary
2. Describe the existing topography. Indicate contours on the site map.
2. GS C mart s . 1...1....\. s Za P°•s�" ,
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
ere_ l ere_ K.. vuove:;✓e- t.'�-CVvw _ LOrva pl k 1 b-et 1,0n3T re.. iv/' 70 yrs.
Vie- 4 �, r sr a--z.i"-_ i- �n,y . N o -kren. 1 s t,ry Le/ily Oti t r ( /
4. Describe the existing soils. Indicate soil type on the site map. `J
S a.%A (uonn.
5. Describe the existing site hydrology(i.e.,drainage;behavior of water on the site above,below, and on the ground). Indicate
existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if
applicable,and indicate acreage of each.
Ro-i,., t..re.4-ar 4. o oso r•Ltc� (01 eo4$r rt
6. Describe any excess levels of noise generated by the proposed use or activity:
Nr /C APPROVED
STORMWATER PLAN
2005
Storrnwater B 's JUL - g
stormwater site plan template.doc—rev.10/122003 Required
, s
1EFFERSO OU TY
DEPT.OF C , DE L ME
SIGNATURE:
13. Describe the water quality system.
NA
14. Describe the conveyance system analysis and design.
,VQ
15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
—1171-4
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code.
NA
17. Describe the proposed surfacing material.
18. Describe methods for restoration of the site.
NA
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.
A/A
20. List here and indude any special reports or studies conducted to prepare the Stormwater Site Plan.
/VA
21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals indude
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or
restrictions here.
None- V.1„_,9. --
7i) � 1 . 7 -,\fir_ �
.,f•
JUN 2 4 2005 Hi
stannwate[sae pian tenplate.doc-rev.10112.2003
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 section 2.5.2 of the Manual(beginning on page
2-15).
12 Required Elements—Construction SWPPP
1. Mark Clearing1 Limits. J(J�
N 0 J r�v�� !fie eA& �y 1 �'S r ` •
2. Establish Construction Access.
n . u A- arc. . _
3. Control�' Flow Rates. 1 �t
Con1
S c*14w roe kr-. ..
4. Install Sediment Controls. I
N tfi Insi .� I,t_v`& �S l •
5. Stabilize Soils.
MI t Cs)n,s�".ot^ WI 1� ci one i 14,r%vr �
6. Protect Slopes.
Nhe-
7. Protect Drain Inlets.
: n i ^ I Vr
J U N 2 4 2005 './
stormwater sae plan template.doc-rev.10i122003
12 Required Elements-Construction SWPPP(continued)
8. Stabilize Channels aryl Outlets.
*
V O C t\ t7 r ojt
9. Control Pollutants.
o c-V\e ON. oa.S LLt\ v.s e.c1 .
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
NA
11. Maintain Best Management Practices(BMPs). (� 1 1
tql C.PnStY'v doves t„1 t U L rJ-tr F;v rt�ec+ ova. q r-� re./1
C�.r• . `1
12. Manage the/Project.V1\.0--t v� t h o o.s1ir re.
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads).
No SAr•e-o-vv---S , 1 a.K e s L-ref I b
b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400
yards).
3. Environmentally Sensitive Areas.
a. Description of environmentally sensitive areas that are on or adjacent to the site. ,r
A)°ham k i •
JUN 2 4 2005 ` it
stormwater site plan template.dec-rev.10/1212003
9
b. n }Description of special requirements for working in or near environmentally sensitive areas.
0 2-w,l ro S-e rs l t n.rtsS N.2 r^r S Ck.
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).
Novo
5. Construction Phasing.
a. Construction sequence
flrtvc�
Poll b o,r-► -
b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
Provide a proposed construction schedule.
v t.� /4 v S"ck &
II. Wet Season Construction Activities.
a. Proposed wet season construction activities.
NA
b. Proposed wet season construction activities for environmentally sensitive areas.
AlR -
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsible for the initiation of bonds and/or other financial securities.
N
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable.
a. Sediment Ponds/Traps.
b. Diversions. �r
c. Waterways. �- � ,
d. Runoff/Stormwater Detention Calculations l �- has {; ` �' `��,
}} JUN 2 4 2005 ,,' 1/
stormwater sate plan template.doc—rev.10/122003 E + _ �, 10
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.
( DOWN ORRE ATIVE SIGNATURE (DATE
ATEE
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
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