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Home My WebLink AboutBLD2009-00231 4ON L'p • , 4, JEFFERSONCOUNTY 4� • ' \ rt., DEPARTMENT OF COMMUNITY DEVELOPMENT h 621 Sheridan Street• Port Townsend •Washington 98368 -- jo, t;) 360/379-4450 • 360/379-445t. a5 www.co.jefferson.wa.us/commdevelopment .._ Master Permit Application JUL 2 1 2009 MtA.1 OCII'o9(4 1 Project Description(include separate sheets as necessary): _ la Tax Parcel Number 93 3 -,5 9✓ j' ) 3 L Property�Site J/Ci5 yV{? ' ., (acres/square feet) Site Address and/or Directions to Property: Pa 11 I Property Owner(s)of Record: —\ro : ! /4-) • . fs 7 20 I-,'. > X i Telephone: 34 O-3,o/ - /9 7 Fax: email: Mailing Address: .3 7/ 23/-5 ,u/4 -7- .' t 0 Cl,,-,�- r U 1! —' r--,,...). Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies 0 Lot or Road Segregation %Building 0 Critical Areas Stewardship Plan ❑ Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use) 16 Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]** Manufactured Home ; .❑ Modular ❑ Discretionary"D"or Unnamed Use Classification ❑ Commercial* 0 Special Use(Essential Public Facilities)** ❑ Change of Use ❑ Boundary Line Adjustment ❑ Address ❑ Road Approach 0 Short Plat** ❑ Home Business 0 Cottage Industry ❑ Binding Site Plan** yrPropane ❑ Long Plat** ❑Sign - 0 Planned Rural Residential Development(PRRD)/Amendments** • ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration** ❑ Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions** ❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development** ❑Temporary Use 0 Shoreline Management Variance ❑Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference 0 Tree Vegetation Request **Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, if known: • DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE 1. 164•0-V- Date: Z 0—O By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application 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 that he or she wants nor notice. c� Signature: ,- �W� Date: 7- Z(2 Q / 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 r onsibilit for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: i _..—r Date: 7.—Z 0_ 9 9, �.\n__:✓'__..._\+444417 IAT 4C-ififff\TIP TI pno TTC\f'..«.....TIATI F.........\T,f..,....Ae.-..:.e....1.,.,..:,...s 10 na,1,.,- 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: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: • S/,f Ao , 8ro-�<.�. s Co,C . ( �,) ,7�I: - _` L ( ) MAILING ADDRESS: 3)7 a, ._5_,/D a ,y:r if-f) rhl,.n.,f , : EMAIL: / CONTRACTOR'S LICENSE WAINS NUMBER: 8 15/-/0,1— 2 9 3 D 6 NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: X'New $ Wood Existing: C ❑ Sewer ❑ Addition ❑ Steel Proposed: a Bank 0 Community System ❑ Alteration/Remodel 0 Concrete Total: 2 Height; ❑ Individual System O Repair ❑ Masonry /,- SEP Permit# 0 b- 30 O Demolition ❑ Other: Bedrooms: Water Supply: Existing: 0 Setback: 0 Private well .A4'Two Party Type of Heat: Proposed Total: ❑ Public .._ - a :, Name of System: J 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 and/or Appliance Installation permit,mark all items below that apply: i Underground Tank (Above ground TirikT Size of Propane Tank: 7 i Heat Stov i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove I Other its 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. S Square Footage Current Proposed FQface Use ,, ut .:._, :Revlsipjl.` .. , Main Floor Heated H Bld App Review: /303 . ,,`baJ°3 `73. o0 2nd Floor Heated Consistency Review: a13. 00 Other Heated r� Base fee: I 15 O."J5 Mezzanine Additional Section: Heated Basement Plan Check fee: 4 71 p n Unheated Basement - State Surcharge fee: r D^ Other Unheated 1 Pot Water Review fee: QO 00 Garage/Carport SUBTOTAL a a b s,-1 l -Becks 'KJ(C- k 911/Rd Approach fee: Gthef- ID---G 2 8B 'Via-. TOTAL: $ a aii3,O, qT Receipt Number: I b g Z3 Cash/Check Number: 1 v-13 ESTIMATED COST(REQUIRED) / lael L]-lk) ate •Fair market value of all labor and materials foun ion to fingA 1 als: G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc i • • csONco q1 JEFFERSON COUNTY . q 144. 1 DEPARTMENT OF COMMUNITY DE 1 ELOPMENT jut_ 2 1 2009 4, jipgro. 4 621 Sheridan Street- Port Townsend • Washcngton 96368 NCO 360/379-4450 •360/379-4451 Fax httpf/www,co.Jefferson.wa.us/commdevelopment/ J STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLAIf -aLt , - PROJECT/APPLICANT NAME: hf j i�Ago.D Please answer all of the following applicant may choose to either incorporate the elements into the general t of your ability. plot plant oer the Master Land.Use Appliuestion calls for depictioncation on a site map, it a separate stormwater site plan map. APPucation or to submit a Project Overview 1. Describe the proposed developed conditions of.the site.:Indicate. site map. Potion and relative size of proposed improvements on the f In/ -4.5 dc5 • ne21 `kor a.- �pc� 1�i� �� -! :. .. o 7r,,r�s /iF -ll 0 r I//aid I Existing Conditions Summary . : 'F�,i• ;I: ::.`• tc+:a rt z r r; r.. •:. .• •'r . ...._ . , tt ;.:..,. Describe the existing topography. Indicate —• _..- • 3. Describe the existing vegetation. Indicate native '4 o 4-e'ns w, ? tati0n areas On the site Irtap. 4. Describe the existing soils. Indicate soil type on the site map. 5. Describe the existin g site hydrology(i.e.,drainage;behavior of water on the site—above,below,and on the rou existing stormwater drainage to and from the site on the site map. Depict separateg 9 resit Indicate applicable,and Indicate acreage of each. drainage basins on the site map, if cat.- 1 .5 l ! -�r.. "') I i. < . 6. Describe any excess levels of noise generated by the proposed use or activity. f1 S E P 2 4 2009 ormwa ' • �` i Requir- " ��R WA" —dip :;- REEFER D ' �/ DEPT.OF C't r 011/U.. PMEN SIGNATUR. A mi., �., • • • 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. ;4- • 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.). Permanent Stormwater Control Plan • • This portion of the Stormwater Site Plan consists of the selection and Installation.of Abe 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 lbw control facilities are not exceeded. g, Describe.:ihe developedaita.hydrology,as ..ro _ . -� ..._. ._.... _-. .. P Posed. Indicate whether stormwater-will be fully-dispersed-(f:e;per BIrAP- In the Manual)or;If not,'what types of stormwater flow control will tie utilized for he site 3r s within the site. Locate these facilities on the site plan and differentiate pacific iliiresltold dtscfiarge areas Proposed faalities . ' 1 // _ Q ? 81rZgr 'Utiestin'cy` '3 10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan an¢.differentiate proposed facilities from existing facilities. [This is normally for'large"projects or projects that involve the potential for dispersion of-contaminants.] 11. Describe the performance goals and standards applicable to the project. 711//4. 12. Describe the How control system. • -V7 . .T • 13. Describe the water quality system. • . J U L 2 1 2009 • 14. Describe the conveyance system analysis and design. • 1 / 1. • 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. 1147p •ZED, 1 r• it �� ; b�c�- 1 r',i7 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the • Uniform Building Code.. . • • g U C -C; I I I n 9 a 5 rr;.- fir-- c+r@ t n d •C oi1,.> r•fc,(. -0 s) • 17. Describe the proposed surfacing material. ` C'u Lit I o n d r1 clt.'-1r _. _ . 18. Describe methods for restoration of the site. • • 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 indude ,J[st the Manuals here. . . ' 20. List here and include any special reports or studies conducted to prepare-the Stormwater Site Plan. • • 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. w CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BM template that follows must be installed on the ground during all construction phases of the project. preventing sediment and erosion impacts to environmentally sensitive areas Ps indicated by the applicant in the Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidanceThe proponent is responsible for Pollution P. off-site areas.guidance, the particularly with ruralun Stormwaterall with residential SECTION I-CONSTRUCTION SWPpp NARRATIVE 1. Construction Stormwater Pollution Plan Elements. willo se addressed.St Identify theP type and location of BMElements. used to Describe sans each of the Cons to the proposal,d y in satisfy the required element. If an elementon SWPPP notes been or 2-15). • writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page 12 Required Elements-Construction SWPPP g 1. Mark Clearing Limits. • /`0 _7L /i,,0.i f q n • • 2. Establish Construction "Access. .- .. . - G ! jam`. ! • 3. Control Flow Rates.. .... .. ----- - - eav -_ - i- u /1 .. • 4. install Sediment Controls. J,€ 4e a„ ' ; 1 I,) 9 , f, `moo �`, rye ,-,ram ' , Pre' �'c, f ( `�7�r h/ 6ti�r C 5- Stabilize Soils. 0"f--i /i C J.`CLk 1/-44 A 0/-1 Ap r; ° 1 f i / air. /, . r YC " Gt / c lee rn .� 6. Protect Slopes. 'te% ,. yr. tri: r ! 3r t • 7. Protect Drain Inlets. • 0cfrc" S ale n l • • JUL 2 1 2009 12 Required Elements—Construction SWPPP(continued) I 8. Stabilize Channels and Outlets. l , f 2n\f h_ �b- - 'fee / , , c .' , u pr 'ei -i due. , o I, ,/r* ,.V ort f 01-. 9. Control Pollutants. j_ i D -, s i.5 d c'•�y�psr�Gi' D-1 we r •c rfy a ri d & - r C 0/l c...-e .1e -1,-L. e. is 5 1-, / //1?G C/Yc,nr� Di-4 ;tt 347. rA9 -0. cL re: . 10. Control De-Watering(the act of pumping groundwater or st:ormwater away from an active construction site). Doi,' -1- .sec f-fi , s 10 4e a P ru 4 fr,a,,... as f:�c� . ; 3 r/a.--/ Z ik we, 71 e i" diet 1 cringe- fo A e S r ie - i. 11. Maintain Best Manapryement Practices(BMPs). / J O"Ic C —CO e,.h r I i It r S I n K`� 41 ► .S �/1 C CIJit/ w ti.G.co -Flit raan d ccrn .S71alatC ad/z � j IN - . . - .. . . . . -- 12. Manage the Project: " - r :. -.-:-�vt,s-r-T:' ` '. -_. 73.3rif.,;..r- . - :.—/ - ,•.-ram.- ,.: ::0r,._ .. L?""+ , / rp J e e I- r s1 di a. v .r et,_,5 d t, • tvicii4;:.,,- ::f ra "`-=:..,.,:- -b 4! Ems, li fp la et • o I r` T- 4.e-n-r- i- t 4 .be 7/11.e- 4.eltet 1.. t•r -e O4.e Ivor c 2. Adjacent Areas. • a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). • J . 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. • 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, 1 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 properly. • — —oq (LANDOWNER OR AUTHORIZED REPR&ENTAT1VE SIGNATURE) (DATE) • THIS SPACE MAY BE USED FOR ADDITIONAL-NOTES,1F NEEDED: ,`; : -�i •. "`"::;`L`:.'..:"•.. • • • • • • • •