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HomeMy WebLinkAboutBLD2010-00306 Jefferson County Building Division Permit Number: BLD10-00306 Applicant: AMERSON BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2009 International Building Codes To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection. Requests received after 7:00 AM will not be scheduled for that day's inspections. ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries. The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection Inspection Item Date Approval Signature Notes Setbacks 1_ p 5 STA124c Minimum setback from East Price Street right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 20 feet. Erosion Control SEE CONDITIONS 2&3 Foundation Footing ��_),(0 SLR �� ,n it Footing Drains (2 L. V Y' Foundation Stem Wall Underground Plumbing Under Floor Framing Straps(hold downs) Ext. Shear Wall Nailing `"t -(/ ,.,/, Rough-in Plumbing �f/� Framing ) 'i( PrB /O e d ►^orovt c„�i�clay✓ ;� cr ;�.e.e_� c',�t'ff. Blocking S" r ` ` d�s�! -t -ri /�? /!i Airseal r ^ // Insulation:Walls 3()`4't( J , pA J /- ` t rl C ktc, Insulation: Floors /n� /� 1 / , !X' Insulation: Ceiling I, 91, Int. Shear Wall Nailing Wallboard Nailing 3L11 / Gas Line: Interior ✓ Gas Line: Exterior Propane Tank Heat/Chimney Clearance Drywell/Alt Drainage 1L_L' d ,,I .,f /L(, SEE CONDITION I FOR DRYWELLS s E 4 Address Posted li l FINAL INSPECTION )p' -/ce / t l i FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR MLA10-00318 IBUILDING PERMIT APPLICAION Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD10-00306 Received Date: 8/25/2010 SITE ADDRESS: 291 E PRICE ST PORT HADLOCK, 98339 OWNER: RICHARD T AMERSON PHONE: 360-316-9159 MARIE L AMERSON 2109 LANDES ST PORT TOWNSEND WA 983687816 IRONDALE SUBDIVISION: Block: 24 Lot: 34-39 PARCEL NUMBER: 961802410 Section: 35 Township: 30 N Range: 01 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NSFR TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 680 VALUATION 130,000.00 ADD'L: 628 HEAT TYPE: EEE CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: 680 #OF STORIES: OCCUPANCY: CONST TYPE: 5N OTHER: SHORELINE: GARA CONST TYPE: DECKLE 255 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 3 Total: 3 Total: 3 Routing Date: .(g..z(cr - Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,161.75 LYK 08/25/10 119995 APPHCV1 Plan Check $755.14 LYK 08/25/10 119995 State Building Code $4.50 LYK 08/25/10 119995 NOV I U)0 Total: $1,921.39 Jefferson County Planning &Building Department • S CONDITIONS for Building Permit# :BLD10-00306 1.) 2005 DOE STORMWATER MANUAL DRYWELL DESIGN CRITERIA ALL INFILTRATION SYSTEMS SHOULD BE AT LEAST 10 FEET FROM ANY STRUCTURE, PROPERTY LINE, OR SENSITIVE AREA. FOR SITE WITH SEPTIC SYSTEMS, INFILTRATION SYSTEMS MUST BE DOWNGRADIENT OF THE DRAINFIELD UNLESS THE SITE TOPOGRAPHY CLEARLY PROHIBITS SUBSURFACE FLOWS FROM INTERSECTING THE DRAINFIELD. DRYWELL BOTTOMS MUST BE A MINIMUM OF 1 FOOT ABOVE SEASONAL HIGH GROUNDWATER LEVEL OR IMPERMEABLE SOIL LAYERS. EACH DRYWELL MAY SERVE UP TO 1000 SQUARE FEET OF IMPERVIOUS SURFACE FOR EITHER MEDIUM SANDS OR COURSE SANDS. TYPICALLY DRYWELLS ARE 48 INCHES IN DIAMETER (MINIMUM) AND HAVE A DEPTH OF 5 FEET (4 FEET OF GRAVEL AND 1 FOOT OF SUITABLE COVER MATERIAL). FILTER FABRIC (GEOTEXTILE) MUST BE PLACED ON TOP OF THE DRAIN ROCK AND ON TRENCH OR DRYWELL SIDES PRIOR TO BACKFILLING. SPACING BETWEEN DRYWELLS MUST BE A MINIMUM OF 4 FEET. 2.) A SILT FENCE SHALL BE INSTALLED WEST OF THE LANDSLIDE HAZARD AREA BUFFER PRIOR TO ANY LAND DISTURBING ACTIVITY. APPLICANT/CONTRACTOR SHALL BE RESPONSIBLE TO MAKE SURE THAT SILT DOES NOT FLOW OVER THE TOP OF THE STEEP BANK. THE MINIMUM HEIGHT OF THE TOP OF SILT FENCE SHALL BE 2 FEET AND THE MAXIMUM HEIGHT SHALL BE 2 1/2 FEET ABOVE THE ORIGINAL GROUND SURFACE. THE SILT FENCE SHALL BE BURIED IN A TRENCH TO A MINIMUM DEPTH OF 5 INCHES BELOW THE GROUND SURFACE. THE TRENCH SHALL BE BACKFILLED AND THE SOIL TAMPED IN PLACE OVER THE BURIED PORTION OF THE SILT FENCE, SUCH THAT NO FLOW CAN PASS BENEATH THE FENCE AND SCOURING CAN NOT OCCUR. ANY DAMAGE TO THE SILT FENCE SHALL BE REPAIRED IMMEDIATELY. SEDIMENT DEPOSITS SHALL EITHER BE REMOVED WHEN THE DEPOSIT REACHES APPROXIMATELY ONE-THIRD THE HEIGHT OF THE SILT FENCE, OR A SECOND SILT FENCE SHALL BE INSTALLED. 3.) CONSTRUCTION ENTRANCES ... ALL BE STABILIZED WHEREVER TRAFf WILL BE LEAVING A CONSTRUCTION SITE AND TRAVELING ON PAVED ROADS OR OTHER PAVED AREAS WITHIN 1,000 FEET OF THE SITE. THE ENTRANCE SHALL BE CONSTRUCTED ON A FIRM COMPACTED SUBGRADE. QUARRY SPALLS (OR HOG FUEL) SHALL BE ADDED IF THE PAD IS NO LONGER IN ACCORDANCE WITH THE SPECIFICATIONS. (BMP C105, 2005 DOE STORMWATER MANUAL). ANY SEDIMENT THAT IS TRACKED ONTO PAVEMENT SHALL BE REMOVED BY SHOVELING OR STREET SWEEPING. THE SEDIMENT COLLECTED BY SWEEPING SHALL BE REMOVED OR STABILIZED ON STIE. ANY QUARRY SPALLS THAT ARE LOOSENED FROM THE PAD, WHICH END UP ON THE ROADWAY SHALL BE REMOVED IMMEDIATELY. UPON PROJECT COMPLETION AND SITE STABILIZATION, ALL CONSTRUCTION ACCESSES INTENDED AS PERMANENT ACCESS FOR MAINTENANCE SHALL BE PERMANENTLY STABILIZED. 4.) Maintaining ground cover will help reduce erosion from surface runoff. Any bare areas that develop should be revegetated. Native low growing vegetation that requires little or no irrigation would be the most beneficial. 5.) 6.) Water line must maintain 10' min. setback from any portion of the septic system. 7.) 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. 8.) 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. 9.) 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." 10.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 11.) 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. 12.) 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. 13.) A Stormwater Site Plan has been bmitted and approved by the Departments 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. 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 2 unlicensed vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor 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 or Chapter 18.18 JCC, and such storage shall meet the requirements of JCC 18.20.100, Automobile wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor vehicles be stored in a critical area. 16.) This parcel is within the Chimacum Creek no shooting area per JCC 8.50. 17.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 18.) Not more than 2 unlicensed vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor 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 or Chapter 18.18 JCC, and such storage shall meet the requirements of JCC 18.20.100, Automobile wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor vehicles be stored in a critical area. 19.) The building height is not to exceed 35 feet. 20.) Minimum setback from East Price Street right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 20 feet. 21.) Exterior lighting for commercial and industrial uses shall not exceed thirty feet(30') in height from the finished grade. 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. 22.) 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. 1 . - • • C JEFFERSON COUNTY ;44 DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend •Washington 98368 �O� 360/379-4450 • 360/379-4451 Fax IND http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# I u ✓ 3 l PROJECT/APPLICANT NAME: Nen,OISOIL) 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. Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. LEvL51.- '17(4 STcrio t3/1-nk' @ eDaf- 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. T( 4-ss / s,2MC -rg s 4. Describe the existing soils. Indicate soil type on the site map. SAIL/19 I ' -' - 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. 0RAI s v ' - APPROVED - STORMWATER PLAN 6. Describe any excess levels of noise generated by the proposed use or activity: NM - 12010 CSI 000 77, v s C ('in.s uch`d7J 66e c J E' _ON COk r,A t t DEPT.O C i, Y D PMEhIT stormW IV' SIGN E: I,L �/ 411,4L Requi0e stormwater site plan template—rev.10/21/2008 v 5 • • 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. CSA /S ui J s 7A 34,6 Sty e 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.). / j/CJ i -ro p__'► 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 the site plan and differentiate proposed facilities from existing facilities. 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 and 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. d 1M Pic i 20 Gf-filo2s 13 Fir /s 2. Describe the flow control system.. O(C w—i w I%a ti R-A-1 lv stormwater site plan template—rev.10/21/2008 6 • 13. Describe the water quality system. CI 7r LA-TA cv2 14. Describe the conveyance system analysis and design. r p(2 ' bJ i-ci-Z- 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. 17. Describe the proposed surfacing material. A 18. Describe methods for restoration of the site. IWPL4IV-T L 41' to Scef-eikti 4 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. PA) N - 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. NoVE- stormwater site plan template—rev.10/21/2008 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 Volume II Section 3.2.3 of the Manual (beginning on page 3-7). 12 Required Elements-Construction SWPPP 1. Mark Clearing Limits. SI L-y 1'2wC E 2. Establish Construction Access. C� "TY S 72 C /5 7/lam c 0 re, 3. Control Flow Rates. PULAX (S P(S O 0JaI Wt, J57YLd'-7 1 DR-Irr w� 7t`YZ 4. Install Sediment Controls. Kr A 5. Stabilize Soils. ►J A 6. Protectt Slopes. t JI I l i a co s'rd2 /Lie- Yz s t.-0 o C 7. Protect Drain Inlets. stormwater site plan template—rev.10/21/2008 8 • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. f 9. Control Pollutants. 10. Control De-Watering (the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). Y63 12. Manage the Project. 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). RCgIo b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). PC 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. .S10Pcs (zo ' 771)1-) stormwater site plan template—rev.10/21/2008 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. N % vV v21c.-I w f..JO R 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). 1� L O.J) L-Di AFL -SITC 5. Construction Phasing. a. Construction sequence 010 cD'F E=X/S ( �''10 13v1Li9 id-ohC 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. Dw N( taV I t4 II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. r) N 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. a. Sediment Ponds/Traps. t•f-br b. Diversions. N h c. Waterways. d. Runoff/Stormwater Detention Calculations ��{tk stormwater site plan template—rev.10/21/2008 10 • SECTION II—EROSION AND SEDIMENT CONTROL PLAN Sediment and erosion control measures may be depicted on the master land use application plot plan,a stormwater site plan, and/or a separate Construction SWPPP site plan. This is a checklist to ensure that the following are depicted on a site plan: 1. General. a. Vicinity Map b. Jefferson County Approval Block c. Erosion and Sediment Control Notes 2. Site Plan. a. Legal description of subject property. b. North arrow. c. Indicate boundaries of existing vegetation (e.g.,tree lines,pasture areas, etc.). d. Identify and label areas of potential erosion problems. e. Identify FEMA base flood boundaries and Shoreline Management boundaries(if applicable). f. Show existing and proposed contours. g. Indicate drainage basins and direction of flow for individual drainage areas. h. Label final grade contours and identify developed condition drainage basins. i. Delineate areas that are to be cleared and graded. j. Show all cut and fill slopes indicating top and bottom of slope catch lines. lib 3. Conveyance Systems. a. Designate locations for swales, interceptor trenches, or ditches. b. Show all temporary and permanent drainage pipes,ditches, or cut-off trenches required for erosion&sediment control. c. Provide minimum slope and cover for all temporary pipes or call out pipe inverts. d. Shows grades,dimensions, and direction of flow in all ditches, swales,culverts and pipes. e. Provide details for bypassing off-site runoff around disturbed areas. f. Indicate locations and outlets of any dewatering systems. 4. Location of Detention Best Management Practices(BMPs). Identify location of detention BMPs. 5. Erosion and Sediment Control Facilities. a. Show the locations of sediment trap(s), pond(s), pipes and structures. b. Dimension pond berm widths and inside and outside pond slopes. c. Indicate the trap/pond storage required and the depth, length, and width dimensions. d. Provide typical section views through pond and outlet structure. e. Provide typical details of gravel cone and standpipe, and/or other filtering devices. f. Detail stabilization techniques for outlet/inlet. g. Detail control/restrictor device location and details. h. Specify mulch and/or recommended cover of berms and slopes. i. Provide rock specifications and detail for rock check dam(s), if applicable. j. Specify spacing for rock check dams as required. k. Provide front and side sections of typical rock check dams. I. Indicate the locations and provide details and specifications for silt fabric. m. Locate the construction entrance and provide a detail. 6. Detailed Drawings. Any structural practices used that are not referenced in the Ecology Manual should be explained and illustrated with detailed drawings. 7. Other Pollutant BMPs. Indicate on the site plan the locations of BMPs to be used for the control of pollutants other than sediment(e.g.,concrete wash water). 8. Monitoring Locations. Indicate on the site plan the water quality sampling locations to be used for monitoring water quality on the construction site. Sampling stations should be located upstream and downstream of the project site. stormwater site plan template—rev.10/21/2008 11 • • . Stormwater Site Plan Changes If the desigi...r 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. F... . 7 ibmittal If the project includeo 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 conOrt1(;ted 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 aff ed property. (LANDOWNER OR AU ORIZED REPRESENTATIVE SIGNATURE) (DATE) i THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: L -tormwater site plan template—rev.10/21/2008 12 IIIsox • ' oe� JEFFERSON COUNTY A, DEPARTMENT OF COMMUNITY DEVELOPMENT (-4.1 " PC 621 Sheridan Street• Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax p'$' www.co.jefferson.wa.us/commdevelopment 1"-9YIN Master Permit Application MLA: I 0 'V I Pro-et `Description(include separate sheets as necessary): 3F . Tax Parcel Number: 4- 6 / 3 0 2- /O Property Size: 4 Y-T s- 01 (acres/square feet) Site Address and/or Directions to Property: Property Owner(s)of Record: 1z,! C-in-m-a.c9 Y.__ ti 1 i' 1 E A-r,L .S 0 kJ Telephone: 6 0 3 7� 3 0 3 0 Fax: email: Mailing Address: Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies ❑Lot or Road Segregation Ouilding ❑Critical Areas Stewardship Plan ❑ Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use) 0 Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]** ❑ Manufactured Home 0 Modular ❑Discretionary"D"or Unnamed Use Classification O Commercial* 0 Special Use(Essential Public Facilities)** O Change of Use 0 Boundary Line Adjustment O Address ❑ Road Approach 0 Short Plat** O Home Business 0 Cottage Industry ❑Binding Site Plan** [ 5 O Propane ❑Long Plat** ❑ Sign -. ❑Planned Rurai Residential Development(PRIRD)/Amendments** ' ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration** ❑ Stormwater Management 0 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 0 Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference 0 Tree Vegetation Request **R••uires a Pre-A..lication 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 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 uired later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap ti that h r e wants prior notice. f Signature: ,4--- i7z -J--- Date: / O Z9/6 The actio 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 tederal 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: Date: • • BUILDER STATEMENT • The signer of this s tement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be ass g the resp sibility f the General Contractor for the proposed project. Signature: Date: /i2g25 24/® GENERAL ONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAx:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: pc New Wood Existing: ❑ Sewer ❑ Addition 0 Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: Individual Systems nn ❑ Repair 0 Masonry S P Permit# (U''1 ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Proposed: r�Public T e of Heat: Total• V • N e of System: If this is a Commercial Project you must answer the following; Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy:__— 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: 1 Underground Tank 1 Above ground Tank Size of Propane Tank: 1 Heat Stove i Cook Stove 1 Woodstove 1 Fireplace Insert I Hot Water Tank 1 Pellet Stove 1 Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines,tank location and size,distances from the propane tank to all properly lines,buildings and septic system components, includin the reserve area. Ff '3 } , 3'5 LAC i F . Square Footage Current Proposed F�� rice i..>� . i'; .;? .<r. . 1'�?� . �e ton Main Floor Heated /g 0 `. ®..s.'I EH Bld App Review: ri3 r m Floor Heated 6 2 8 " 3(c 'p Consistency Review: e l 3 Other Heated Base fee: Mezzanine Additional Section: Heated Basement —1 Plan Check fee: I 1 Unheated Basement 6 cc� State Surcharge fee: 4:5.) 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