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APPROVED
SITE PLAN
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PERMIT # III --
07 - 0442
JEFFERSON COUNTY 11Ci
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k,,, cO,� JEFFERSON•LINTY •
alDEPARTMENT OF COMMUNITY DEVELOPMENT AUG —
`' y 1-4 621 Sheridan Street • Port Townsend •Washington 98368 *I '`' '
360/379-4450 • 360/379-4451 Fax
�q� N�,sO� www.co.jefferson.wa.us/commdevelopment {FffJJ NI�iir t) I' �l'V
Master Permit Application MLA: UT' 44.`'D,
Project Description (include separate sheets as necessary):
L)0A' bed Cioir-p0r.T
Tax Parcel Q/ Property
_I Number: (,p Z. 7 0 0 lie Size: 54 4 S (acres/square feet)_
Site Address and/or Directions to Property:
013 66/denv,ew tZA
Property Owner(s)of Record: Z,.,avr^IC. e i/D Pi
Telephone: y2:- 5C7 - osz VS, Fax: cl ti-" 7'0- 515-95- email:G�}v2r.Elg/one Co c14sl,(c;v.
Mailing Address: Z/g0 ft)e-c.j por7'tv.9r /VW -7=_55 'C110911 ayn `it-SCR-7
Applicant/Agent(if different from owner): pi i K t G'i(ci e ii
Telephone: 9Z,�-`-Ii4'-31 b `[ Fax: YZ5-.-77/- 3/�3 email: fri• a.1c1e/N & rilcth (+nk.nif'
Mailing Address: Z'0 s a Se)9 Ii-c-— ii972-e_ W E A/1 0.s/0i7 Gv 14 103 Y&
What kind of Permit?(Check each box that applies
C $wilding ❑Variance(Minor, Major or Reasonable E r. , ims'avirL�}�❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C)** Z ` � �� � I
❑Single Family rage Attached/Detached 0 Discretionary"D"or Unnamed Use Classi'cation
❑ Manufactured Home ❑ Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment AUG — 8 2.4?
❑ Change of Use 0 Short Plat**
❑ Address 0 Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry 0 Long Plat** p (��� d;'�� �����;I,
❑ Propane 0 Planned Rural Residential Development
❑Sign ❑ 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)* 0 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 ❑ Tree Vegetaion Request
*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:
( 7, t/ DESIGNATION OF AGENT
I hereby designate Mi d h ne.l cZ ' _ to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE f� Date: S • 1 - 01
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. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the application h r wants prior notice.
Signature:_ Date: 2' cP— U 7
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 co pliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferab e respon it or adhering to and complying with the ESA. The Applicant has read this disc Amer and signs and dates it below.
Signature%'���c C
Date: �"�
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.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 assumin es ral n�tii{ fill G eral Contractor for the proposed project.
Signature:---- " �,= --C..L 3 = Date: °,•• •-03-U 7
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
CCU y7vi",1 4.3t'' if S?,rc�r/ctzrY�+ hc— (`l2)- ) 77�3i51 ( t j�iT 77y 3 lees
ADDRESS: 9 71 Z f-�`r/c/7,6 4-lay 17'2 3`' EMAIL:`71,4 Q Ci,s/'a,7.--,S�•,If 51;v.4,0-e$ ,4.0,0
CONTRACTOR'S LICENSE WAINS
NUMBER: L'OSJ'0 �� 'cf SO l' I3 NUMBER
ARCHITECT/ENGINEER: /j,,lh 54,7/t1, PHONE ( ) FAX: ( )
MAILING ADDRESS: 6 5.2 0 Z.I Z ST ,fid •y'p,,w0;,,/ EMAIL ._.
Project Type: Frame Type: Bathrooms:"--k- Shoreline: Type of Sewage Disposal:
New 1 Wood Existing: • ❑ Sewer
❑ Addition 0 Steel Proposed- Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete I: Height: ❑ Indivjd0 stem
O Repair 0 Masonry SEP Ixel"lfu
❑ Demolition ❑ Other: Bedrooms: Water Su
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat A Proposed: 0 Public
tJn to Total: Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Aria.
of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Curre 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 Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other
Is this appliance being installed in a Manufactured I Mobile Home? Y5v/,JJIo
When applying fora 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 :*o`r Offi CO,UserOnlj o ti;,; ' Amount . Revision
Main Floor Heated EH Bld App Review: h30W o 5S
2"°Floor Heated 11 FA Consistency Review:
Other Heated Base fee:
. 5l<a. 95
Mezzanine �I'i�' t' Additional Section:
Heated Basement 71�����. • ( ' Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated • Pot Water Review fee:
Garage/Carport ] SUBTOTAL
Decks ! 1E1Approach fei:
isa Co
Other TOTAL: $ t a6%,57
Receipt Number: q-2)1 C
Cash/Check Number:
ESTIMATED COST(REQUIRED) /'j.00 0 — Date: -e,. -„j51_67
•Fair market value of all labor and materials lbundation to finish
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc E,f/E -A L.L CZ 12
• • •
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4s. JEFFERSON COUNTY VJG - 8 ra
kiii. DEPARTMENT OF COMMUNITY DEVELOPMENT
4 ,„ 621 Sheridan Street •• Port Townsend ••Washington 98368 Mf f illNI� �A�IIr
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360/379-4450 • 360/379-4451 Fax
C http://www.co.jefferson.wa.us/commdevelopment/
STORMWATER SITE PLAN SUBMITTAL TEMPLATE
MLA# 011 - L'(D PROJECT/APPLICANT NAME: Z/9 JK`/ ' / 'I./ n
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. ) l n / /
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Witt e.� A, 9- 4 i7 L-�.. 1�' ce..-�.h .4 ram)h U�e lit/C`n� a v—
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Existing Conditions Summary
2. Describe the exi ng topography. Indicate contours on the site ma .
3. Describe the existing vegetation. Indicate native vegetation areas on the site map.
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4. Describe the existing soils. Indicate soil type on the site map.
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.
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6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED
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stormwater site plan ten-plate—rev.10/1/2003 DEFT.OF CO. ET 5
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7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams,
steep slopes,etc.)on the site. Indicate location on the site map.
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8. Describe the general vicinity of the site,including adjacent land uses and structures, utilities, roads, and sensitive/critical areas
(streams,wetl nds,lakes,steep slopes,etc.)
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Permanent Stormwater Control Plan
This portion of the Stormwater Site Plan consists of the selection and installation.of the appropriate stormwater control BMPs
and facilities to remain in place after construction of the project is completed.
`Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious
surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control
facilities are not exceeded.
g. Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30
in the Manual) or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas
within the site. Locate these facilities on�he�e plan��i�eren�at proposed facilities from existing facilities.
a10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed
for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is
normally for`large"projects or projects that involve the potential for dispersion of contaminants.]
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RE('EIVED
11. Describe the perforjnance goals and standards applicable to the project. AUG - 8 Mg
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12.._Describe the flow control system.
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13. Describe the water quality s tern.
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14. Describe the conveyance system analysis and design.
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15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material.
16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the
Uniform Building Code. //zio�fi/- F ( 4YCc-}.J h74,--Ad/59 - C0r►pa 7/e3 it0r
17. Describe the proposed surfacing material.
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18. Describe methods for restoration of the site.
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19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for
"large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals
here. A
20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan.
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21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include
conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or •
restrictions here.
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stormwater site plan template—rev.10/1/2003 7
• •
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 Clearing Limits.
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2. Establish Construction Access.
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3. Control Flow Ratgs.
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4. Install Sediment Controls.
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5. Stabilize Soils.
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6. Protect Slopes. 1
(4 414-
7. Protect Drain Inlets.
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stormwater site plan template—rev.10/1/2003 8
•
• •
12 Required Elements—Construction SWPPP(continued)
8. Stabilize Channelswand Outlets. Ikdl%� q i ,
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9. Control Pollutants. (ffirfINUN1;II11NI101:I5
10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site).
11. Maintain Best Management Practice (BMPs).
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12. Manage the Project. 7(. r} /f
411) (�O S 7'O �'` B T o• `/ .>�r(/L / u/''e}
2. Adjacent Areas.
a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential
areas,roads). /
o f !dc_t_ S44
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.
stonnwater site plan template—rev.1CY1/2003 9
•
• •
b. Description of special re uirements for working in or near environmentally sensitive areas.
4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site
soils(e.g.,erodibility,set ability,permeability,depth,texture,soil structure).
5. Construction Phasing.
a. Construction sequence
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b. Construction phasing(if proposed)
6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual).
I. Provide a proposed construction schedule.
37go-I- / un-�!<. /9)1/45- ,a-e<3-.0./
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II. Wet Season Construction Activities.
a. Proposed wet season constructactivities.
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b. Proposed wet season construction,activities for environmentally sensitive areas.
7. Financial/Ownership Responsibilities.
a. Identify the property owner responsi I le for th initiation of bonds . /9l'other financial securities.
i u rr'-e- be,(6 .?
b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation
impacts.
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8. Engineering Calculations. Provide Design Cal ulations on a separate sheet for the following,if apT le. n
27
a. Sediment Ponds/Traps. ` ` �
b. Diversions.c. Waterways. (FfFfBII (ILlN41 '
d. Runoff/Stormwater Detention Calculations
stormwater site plan template—rev.10/12003 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.
CJ
(LANDO NE OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED:
RECERT101
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stormwater site plan template—rev.10/1/2003 12
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DAN PARKS
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OWNER.
LINCOLN•
ST.
- (0 m LOU1k,N: rj
� STRUCTURES INC. PORT LUDLOW, WA 98367 -,
9792 EDMONDS WAY #239 OWNER APPROVAL 1)111:
EDMONDS, WASHINGTON 98020
(425)299-6302 SALES REP.APPRO\TL D\1L
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