HomeMy WebLinkAboutBLD2000-00652 C__AR , 00 I-S(?
BUILDING PERMIT APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD00-00652 Received Date: 10/4/2000
SITE ADDRESS: 275876 HWY 101 ,1 I I
SEQUIM, 98382
APPLICANT: DISCOVERY BAY LEASEHOLDERS ASS PHONE: (360)797-7222
PO BOX 3758
SEQUIM WA 98382
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 002353001 Section: 35 Township: 30 N Range: 02 W
CONTRACTOR: MONROE HOUSE MOVING INC PHONE: (360)765-3917
110 E COLUMBIA ST
QUILCENE WA 98376
ARCHITECT/
ENGINEER :
PROJECT DESCRIPTION: RELOCATE AN EXISTING DECK WITH UTILITY ROOM
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 5,200.00 ADD'L: HEAT TYPE: UH
CODE EDITION. 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: gRAAGE: SHORELINE:
CONST TYPE: ECK: 520 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PARCEL TAGS: YES NO (�
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Flood Plane k
F&W Landslide
Routing Date: I C
S CO Shoreline Aquifer
Forest: Commercial Rural
Pr xlml T- Flat C;q ad it Ions
Type Amount Paid By: Date: Receipt: Approv c ate
Permit $125.25 MAM 10/04/00 34603 : 'lil i IIItAii " • •
Plan Check $37.58 MAM 10/04/00 34603 i.....14 •
State Building Code $4.50 MAM 10/04/00 34603
_W
Total: $167.33 f 0 t'1Of
'•�
/
v V
, ,er„ ei)
is\F_BLD_App_Bld.rpt 10/29/99
STORMWATER CALCULATIONS
Owner/Applicant: Sill eon t.
0 PROPOSED LAND DISTURBING ACTIVITY
Site Address: 9, iil iij tp-it /6/ Drainfield area cleared sq.ft.
°Lt:r `". f J p Driveway Length ft.
O®Z 33-3 00/ X Width ft.
9 Digit Parcel Identification No.: 00 = Total Driveway sq.ft.
Permit Number: Clearing and Grading for Site Development
PLOT PLAN (Well/Structures/Utilities/etc.) sq.ft.
52,6 sq.ft.
INDICATE the following information. Total Land Disturbance 5 2-0 sq.ft.
Draw entire parcel to scale. Indicate scale of plot plan:
One inch equals 2 IMPERVIOUS SURFACE
Proposed Structures (all roof area) 5-24 sq.ft.
❑ 1. North arrow Existing Structures (all roof area) sq.ft.
2. All property boundaries and dimensions Sidewalks sq.ft.
0 3. Names of adjacent streets Concrete Patios sq.ft.
4. Driveway/s & parking spaces Proposed:
2.1 5. Major features such as ravines, Driveway Length ft.
seasonal creeks, bodies of water, etc. X Width ft.
6. Septic tank, drainfield and reserve area location, = Total Driveway sq.ft.
existing or proposed, and distance to Total Impervious Surface to sq.ft.
closest structure
21 7. Sewer lines The Stormwater Manual sets forth the following Small Parcel
Minimum Requirements:
8. Wells and/or water lines • Construction Access Route Stabilization:
9. Neighboring wells within 1 50 feet Construction vehicle access shall be, whenever feasible,
limited to one route. Access points shall be stabilized with
0 10. Paved surfaces (patios) quarry spells or crushed rock to minimize the tracking of
1 1. Structures, existing and/or proposed sediment onto public roads. If sediment is inadvertently
transported onto public roads, roads shall be cleaned
12. Setbacks (distances to property thoroughly at the end of the day by shoveling or sweeping.
Street washing should only be done after the bulk of the
boundaries, structures, banks, sediment has been removed by sweeping.
and shorelines) • Stabilization of Exposed Soil:
All exposed and unworried soil shall be stabilized by sodding,
1 3. Easements for access or utilities seeding, mulching, plastic covering, application of gravel base
14. Arrows showing direction of slope on roads and driveways, or other appropriate means within
seven days during the period from May 1 to September 30
assume an elevation of 100 feet at one and within two days during the period from October 1 to April
lot corner and indicate the other lot 30. Mulch shall be applied to a minimum depth of two inches.
• Protection of Adjacent Properties:
corner elevations in relation to it Adjacent properties shall be protected from sediment
deposition by appropriate use of vegetative buffer strips,
sediment barriers or filters, dikes, mulching, or by a
FOR APPLICATIONS ADJOINING SHORELINES, combination of these measures and other appropriate Best
Management Practices (BMPs).
INDICATE: • Maintenance:
0 15. Ordinary high water mark All erosion and sediment control BMPs shall be regularly
inspected and maintained to ensure continued performance of
❑ 16. Top of bank, if over 10 feet high their intended function.
0 17. Slope of bank in degrees • Other Appropriate BMPs as required by Jefferson
County to mitigate the effects of increased runoff shall be
applied.
H:\HOME\PLNCNTR\FORMS\PLOTPLN.FRM9/97
• ' ; I
BUILDING
PERMIT APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD00-00652 Received Date: 10/4/2000
SITE ADDRESS: 275876 HWY 101 11 1 M`'6
SEQUIM, 98382
APPLICANT: DISCOVERY BAY LEASEHOLDERS ASS PHONE: (360)797-7222
PO BOX 3758
SEQUIM WA 98382
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 002353001 Section: 35 Township: 30 N Range: 02 W
CONTRACTOR: MONROE HOUSE MOVING INC PHONE: (360)765-3917
110 E COLUMBIA ST
QUILCENE WA 98376
ARCH ITECT/
ENGINEER :
PROJECT DESCRIPTION: RELOCATE AN EXISTING DECK WITH UTILITY ROOM
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 5,200.00 ADD'L: HEAT TYPE: UH
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: 520 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Flood Plane
F&W Landslide
Routing Date: I 0
S Shoreline Aquifer
Forest: Commercial Rural
1-'r ximlty - Hat Uor1d tions
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $125.25 MAM 10/04/00 34603 IfFITED
Plan Check $37.58 MAM 10/04/00 34603
State Building Code $4.50 MAM 10/04/00 34603
Total: $167.33 0
Jefferson County Planning
&Building Department
i:\F_BLD_App_Bld.rpt 10/29/99
.
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
(360)379-4450 FAX(360)379-4451 (800) 831-2678
PERMIT #: BLD00-00652 Received Date 10/4/2000
SITE ADDRESS: 275876 HWY 101 # 115 Issue Date 10/30/2000
SEQUIM, 98382 Expiration Date 10/30/2001
APPLICANT: S. TOBIN DISCOVERY BAY LEASEHOLDERS ASS PHONE: (360)797-7222
PO BOX 3758
SEQUIM WA 98382
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 002353001 Section: 35 Township: 30 N Range: 02 W
CONTRACTOR: MONROE HOUSE MOVING INC PHONE: (360)765-3917
110 E COLUMBIA ST
QUILCENE WA 98376
LOAN LENDER/
BOND HOLDER:
PROJECT DESCRIPTION RELOCATE AN EXISTING DECK WITH UTILITY ROOM
REQUIRED INSPECTIONS:
[ ] Footings/Setbacks (Shoreline Setbacks):
[ ] Foundation:
[ ] Underground Plumbing/Underground Insulation:
[ ] Shear Wall:
[ ] Framing/Plumbing:
[ ] Propane Tank/Lines:
[ ] Insulation:
[ ] Sheetrock: /
[ ] Final/Occupancy Approval: ` S1200( B1k/ ) hl —�� in/31/n7
HEALTH DEPARTMENT 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.
Inspector's Phone Hours 8:00 a.m. - 9:00 a.m.
SPECIAL CONDITIONS MAY APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
BUILDING PERMIT APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD00-00517 Received Date: 8/3/2000
SITE ADDRESS: 275876 HWY 101 #31
SEQUIM, 98382
APPLICANT: DISCOVERY BAY LEASEHOLDERS ASS PHONE: c',
PO BOX 2351 c-
SEQUIM WA 98382 i
c..
SUBDIVISION: Block: Lot: cs.
PARCEL NUMBER: 002353001 Section: 35 Township: 30 N Range: 02 W
CONTRACTOR: A-1 CONSTRUCTION PHONE: 683-7959
PO BOX 884
SEQUIM WA 98382
StovmwatereliFia
' Contractor's License Al CON**245LD Expires 09/22/2000 ;/ 5)t C 7
ARCHITECT/
ENGINEER : Critical Area
Review q/15)0o
PROJECT DESCRIPTION: UTILITY ROOM
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 4,550.00 ADD'L: HEAT TYPE: UH
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: 230 SHORELINE:
CONST TYPE: DECK: 225 SETBACK:
BANK HEIGHT: �
SEWAGE DISPOSAL: CMY ;I-1 `. 1 0
WATER SYSTEM: PUBLIC PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Flood Plane
F&W Landslide
Routing Date: Shoreline Aquifer
Forest: Commercial Rural
—Proximity - NIat c:o d dons
Type Amount Paid By: Date: Receipt: Approved ate
Permit $111.25 MAM 08/03/00 32278
Plan Check $33.38 MAM 08/03/00 32278
State Building Code $4.50 MAM 08/03/00 32278
Total: $149.13
is\F_BLD_App_Bld.rpt 10/29/99
0 •
Jeffers6�3 stl'BBt,P(N't OWll WA '�]County Department of Conummity �� t
O(--e-- 0/4---&--
Ai, 450
G
'`.:� rm : l A O 0 o
? - r'n
, [n
Project Description: - '_4T T'i;it,pii l
Building Type: Project Type: Frame Type:
Single Family - Newe Wood
Garage Attached/Detached Addition 1 Steel
Modular = Alteration/Remodel = Concrete
Commercial 1 Repair = Masonry
Multi-family/#of Units Demolition 1 Other:
Industrial / CT/ #, ,
Other: f :4 V l r;r T,1 ';mil l' p ,
Bedrooms: Bathrooms: Type of Sewage Disposal: Type of Heat:
Choose one:
Existing: Existing: Sewer 1 Community System Electricity 1 Oil
Proposed: Proposed: 2 Individual System Woodstove 1 Propane
Total: Total: If not sewer,fill out the following: E Heat Pump
Conventional - Alternative Other
Water Supply:
I Permit.# SEP
Private well i Two Party Well Public:Name of water system:
Square Footage: For Office Use Only
Main Floor UBC OCCUPANCY GROUP AS
2ND Floor Base fee /A s -
3r Floor Plan Check fee 0 9•5
5-0
Htd Basement State Surcharge fee y
Unhtd Basement "\ Subtotal ( '7 '33
GGarage/Carport � � Pot Water Review fee r
Decks --L...) 911/Rd Approach fee
Commercial 9 TOTAL 1' 7- '3
Industrial Receipt # f::C)3
ki
Other 3'% : , _ Cas. 140
mow-
2
VTo aluatio Initials
or Date ILD/y222=1=t.
Estimated Cost:
If within 200' of the Shoreline,
Distance to Bank or Ordinary High Water Mark ft. Bank Height ft.
By signing the application form,the applicant/owner attests th the information provided herein is true and coueu.to the best of their knowledge. Any material falsehood or any
omission of a material fact made by the applicant/owner with res 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 it's employees,representatives or agents for the purpose of application review and any required later inspections.
Access and right of entry to the plicant's property or structure sh be r ested and shall occur during regular business hours.
Signature: _ .,d4t 7t Date: 10 — V—a 0
STORMWATER CALCULATIONS
Owner/Applicant:7 &n. 429.)
J{ 7�
❑ PROPOSED LAND DISTURBING ACTIVITY
Site Address: ar/c927 S- to/ S 31 Drainfield area cleared
*se-- sq.ft.
Gc,:r• i ('�!' WA �?�38"2" Driveway Length ft.
X Width { — ft.
9 Digit Parcel Identification No.:a() a, 353 l = Total Driveway sq.ft.
Permit Number: Clearing and Grading for Site Development
PLOT PLAN (Well/Structures/Utilities/etc.) sq.ft.
sq.ft.
INDICATE the following information. Total Land Disturbance O sq.ft.
Draw entire parcel to scale. Indicate scale of plot plan:
One inch equals ❑ IMPERVIOUS SURFACE
Proposed Structures (all roof area) 7 S sq.ft.
❑ 1. North arrow Existing Structures (all roof area) 13 L E sq.ft.
• 2. All property boundaries and dimensions Sidewalks sq.ft.
3. Names of adjacent streets Concrete Patios sq.ft.
• 4. Driveway/s & parking spaces Proposed:
❑ 5. Major features such as ravines, Driveway Length — ft.
seasonal creeks, bodies of water, etc. X Width 0 ft.
❑ 6. Septic tank, drainfield and reserve area location, = Total Driveway sq.ft.
existing or proposed, and distance to Total Impervious Surface sq.ft.
closest structure
• 7. Sewer lines The Stormwater Manual sets forth the following Small Parcel
Minimum Requirements:
8. Wells and/or water lines • Construction Access Route Stabilization:
❑ 9. Neighboring wells within 150 feet Construction vehicle access shall be, whenever feasible,
limited to one route. Access points shall be stabilized with
• 10. Paved surfaces (patios) quarry spalls or crushed rock to minimize the tracking of
❑ 1 1. Structures, existing and/or proposed sediment onto public roads. If sediment is inadvertently
transported onto public roads, roads shall be cleaned
❑ 12. Setbacks (distances to property thoroughly at the end of the day by shoveling or sweeping.
Street washing should only be done after the bulk of the
boundaries, structures, banks, sediment has been removed by sweeping.
and shorelines) • Stabilization of Exposed Soil:
All exposed and unworried soil shall be stabilized by sodding,
1 3. Easements for access or utilities seeding, mulching, plastic covering, application of gravel base
LI 14. Arrows showing direction of slope-- on roads and driveways, or other appropriate means within
seven days during the period from May 1 to September 30
assume an elevation of 100 feet at one and within two days during the period from October 1 to April
lot corner and indicate the other lot 30. Mulch shall be applied to a minimum depth of two inches.
• Protection of Adjacent Properties:
corner elevations in relation to it Adjacent properties shall be protected from sediment
deposition by appropriate use of vegetative buffer strips,
sediment barriers or filters, dikes, mulching, or by a
FOR APPLICATIONS ADJOINING SHORELINES, combination of these measures and other appropriate Best
Management Practices (BMPs).
INDICATE: • Maintenance:
❑ 15. Ordinary high water mark All erosion and sediment control BMPs shall be regularly
inspected and maintained to ensure continued performance of
❑ 16. Top of bank, if over 10 feet high their intended function.
El 17. Slope of bank in degrees • Other Appropriate BMPs as required by Jefferson
County to mitigate the effects of increased runoff shall be
applied.
H:\HOME\PLNCNTR\FORMS\PLOTPLN.FRM9/97
• 0
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360) 379-4450
CRITICAL AREA STANDARD WAIVER
Applicant: DISCOVERY BAY LEASEHOLDERS ASS
PO BOX 2351
SEQUIM WA 98382
Critical Area Review Case Number: CAR00-00366
Project Description: utility room
Parcel Number: 002353001 S-T-R: 35-30N-02W
Site Address: 275876 HWY 101 #31
SEQUIM WA, 98382
FINDING: The development, as proposed and portrayed on the Universal Plot Plan, does not encroach on
an identified critical area nor any associated buffers.
CONCLUSION: The proposed development meets the waiver requirements established in Jefferson County
Ordinance 05-0509-94.
CONDITION: The development shall be as p oposed and portrayed on the Universal Plot Plan. Deviation,
additions or relocation of pro s development activities will require further review pursuant to
the Jefferson County Critical r a Ordinance.
\ (-----1
, kir'---..----"-- Al
Depar ent of Community Development St
r'
c: File
I:\F_CAR_Waiver_Standrd.rpt 12/13/99
Jefferson County Department of Community Development August 15, 2000
621 Sheridan Street, Port Townsend, WA 98368
(360) 379-4450
CRITICAL AREA STANDARD WAIVER
Applicant: DISCOVERY BAY LEASEHOLDERS ASS
PO BOX 2351
SEQUIM WA 98382
Critical Area Review Case Number: CAR00-00366
Project Description: utility room
Parcel Number: 002353001 S-T-R: 35-30N-02W
Site Address: 275876 HWY 101 #31
SEQUIM WA, 98382
FINDING: The development, as proposed and portrayed on the Universal Plot Plan, does not encroach on
an identified critical area nor any associated buffers.
CONCLUSION: The proposed development meets the waiver requirements established in Jefferson County
Ordinance 05-0509-94.
CONDITION: The development shall be as proposed and portrayed on the Universal Plot Plan. Deviation,
additions or relocation of proposed development activities will require further review pursuant to
the Jefferson County Critical Areas Ordinance.
t
Department of Community Development Staff
c: File
is\F_CAR_Waiver_Standrd.rpt 12/13/99
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
CRITICAL AREAS QUESTIONNAIRE
Applicant Name
x Building Application _ Land Use Application _ Shoreline Application
On-site Sewage Application _ Subdivision Application Other:
1 . Is there any standing or running water on the surface of the _ Yes ,X No
property or on any nearby property at any time during the year?
If YES, please describe:
2. Has any portion of the property or any nearby property ever been _ Yes )/ No
identified as a wetland or swamp?
If YES, please describe:
3. Are any willows, skunk cabbage, alders, or cottonwoods present _ Yes No
on your property or adjacent properties?
If YES, please describe:
4. Are there any indications on any portion of the property or on any _ YES x No
nearby property of rockslides, earthflows, mudflows, or landslides?
If YES, please describe:
5. Please indicate which line best represents the steepest slope found
on your property. (Check appropriate box)
a o 4 a ❑
/ / /
/ / / / / / /
/ / / / / / /
/ / / / / / / ri
/ / / / / / / /
! / / / / / I ,
/ / / / / / / /
/ / / / / / /, // /'❑
/ /
//// //// / // /,/ ,' ///
/ / / / / / / // // //'❑
/ / / / / / / / / /0 /I / / /
/ / / / / / / / / /
/!/ / / / / / / / '�-/
/ / _-'❑
////// / / / /
//// —C]
(Questionnaire Continues on Back)
Page 1 of 2
6. Does the site have steep slopes with little to no vegetation? _ YES X Ng
If YES, please describe:
7. Does the site contain high percentages of silt and/or very fine s YES y NO
sand?
If YES, please describe:
8. Does the site contain ground water seepage or springs near the _ YES ' NO
surface of the ground?
If YES, please describe:
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their
knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner 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 it's employees, representatives or agents for the purpose of
application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requested and
shall occur during regular business hours.
Signatur Date k/S K-
t1' ` i
FOR OFFICE USE ONLY
❑ Wetlands ❑ Seismic
CRITICAL AREAS ON OR ❑ Aquifer Recharge Area (zone_) ❑ Fish & Wildlife Area 1
IMMEDIATELY ADJACENT TO SITE: ❑ Frequently Flooded Area ❑ Fish & Wildlife Area 2
❑ Erosion 0 Landslide
:Seismic ❑ Commercial Forest
Section Township North Range
Parcel Number: Parcel Size:
Comprehensive Plan Land Use Designation: Reviewed by:
Community Plan: Date:
Page 2 of 2
h:\home\pincntr\forms\car.doc 1/00
•
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
CRITICAL AREAS QUESTIONNAIRE
Applicant Name
Budding Application Land Use Application _ Shoreline Application
Cr-site Sewage Application Subdivision Application '` Other:
1 . Is there any standing or running water on the surface of the Yes t,,,r-'";Uo
property or on any nearby property at any time during the year?
If YES, please describe:
2. Has any portion of the property or any nearby property ever been _ Yes ' No
identified as a wetland or swamp?
If YES, please describe:
3. Are any willows, skunk cabbage, alders, or cottonwoods present Yes No
on your property or adjacent properties?
If YES, please describe:
4. Are there any indications on any portion of the property or on any YES No
nearby property of rockslides, earthflows, mudflows, or landslides?
if YES, please describe:
5. Please indicate which line best represents the steepest slope found
on your property. (Check appropriate box)
r-' Y U
/ / / / / %
/ / / / / / //,
I / / / / / /
/ / / / / / / 1
I / / / / / /
/ / / / / / /
I / / / / / /
I / / / / / / / -.
/ / / / / / / / /•
1 / / / / / /
/ / / / / / /
/ / / / / / / / /
/
I / / / / / /
/ / / / / / / / /
I / / / / / / / /�
1 / ! / / / / / / ii''//
rid // / /
I////// /i/•- -ice
(Questionnaire Continues on Back)
Pagel of
6. Does the site have steep slopes with little to no vegetation? _ YES ti,` N,
If YES, please describe:
7. Does the site contain high percentages of silt and/or very fine _ YES ,,r`fNC
sand?
If YES, please describe:
8. Does the site contain ground water seepage or springs near the — YES <-'"iNO
surface of the ground?
If YES, please describe:
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of tr.e,:r
knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this application :ac:e:
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 attorneys fee,
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 it's employees, representatives or agents for the purpose
application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requestec arc
shall occur during regular business hours.
Signature Date /Q / Q 0
FOR OFFICE USE ONLY
Wetlands Seismic
CRITICAL AREAS ON OR = Aquifer Recharge Area (zone ) Fish & Wildlife Area 1
IMMEDIATELY ADJACENT TO SITE: 7.. Frequently Flooded Area Fish & Wildlife Area 2
Erosion Landslide
:Seismic Commercial Forest
Section Township North Range
Parcel Number: Parcel Size:
Comprehensive Plan Land Use Designation: Reviewed by:
Community Plan: Date:
Page 2 of 2
h:'home‘pincntr forms\car.doc 1;C0
11
1-o-r 3l DATE
jj'Y (..)/
r ;
//
5 ea 14; 3-- flu e v-1 Q.
t t /Q j 5-0 ,. j
1
' I - _I
I 1
.
17I $
iv'
11
1 X i
(c) i 3;` 1
a; ',, ,i5
i r
_S1
S
i
I
I
C- I
i
-'
I
i --_ + EcxSe311,f'_«j I I'll c s
0 I -(\
� G I ( A
Se-."er ( l T kt�ode( ./l� '_� I' �i 'E'_ �✓ ch
t/�� �-fib ar ', ) � � es i� •
v-LA✓?s /o ' u�dle,t- /o f- -7 // ivt cu,1 mon,N iki,S NiS `44
1'.'1 P`:"-/.
GlcijaL ,T - Q✓�pr%r`✓ (Eas1- /cif
PREPARED BY PAGE
..,.,
. .
-,.
,..„
4- •,......, .
--71?
. c.. ‘...--.
. •c.,......... Ir.<C72-••:-.. (,'' '
r' ----
C
---\
''. -•N.---•-.
..g•-,....Th- G--- •
.„...
--- .'
ir)
, CI. -N.
1, ..
' ..A....
'.,..
'-•.:•-••,'.-„:,.,,
. ,
‘"••••) '',,, .
:-•17 .,„
1../q .
.„.
''-•:..,,
.,
0
'V .. ,-.•
\---•P'' , . ,
\a,
,P, .
• --„%.
. •,-- "` '''-' 5.• `.›.k . .
...„..,. '
' 7
•-N. 4 r\N C, ON,
,'".•
Y fa, • .. _ .
'.•$,. -v; -.,
7)/•r , °N
.• - , . --..
I .,
• ',..,•- 0 7,,,• ‘,.
• •., , ;c Zr..,[z> f„,. /7
o 1 .
•. - ,
1S10,ch '''e' ,, _ .
c,
t.•• ,,,r ..„ A-,
, \..,.
,:•.•.1 ..„.., .N--,.. \''''
„ . , 7.5
..„ r..-
. I)
.
i
,,,, '• ,..... /
.,('
....- ,1/4....../\ -
---z) ,-. -(,--
.•';, ('''' -,
r-1 !
't'N
(.- „. .
(5 .
,...
-4',....„..
•
..,
, ..
N
a I• o r) Cd ti a a a,` . a _
a -- �1 N
v
0 H rza
o CA
U , Q
o y 71:'''
o°
, .
oid
_.
di
v wo
.i
CI a~ Z � O ti k c7 w N ~ � j a.D .
tl. 1`1 ^ -b >
-
tii� o ft
w� T; ft3 p O id � I O Z rO� y •
vTju clv
Y pz i)V G y o \ CA
a.
� ^\ cid " b O � � '!a (IQ _ _ t
} o Qa b b r~ ti
^ .o ca. ,lT bp ppbb V 4-9 �bA 1-1b pp
` v a ov i
o a Q�w � rnrn dcncn ; C7VU ¢ � U
pi—
ww
A
1
/IV
cn
Z
a cc 1 } 5 ul
SN�Vfi13S ti
A
Z F°
o WA 1.`
o
o Z
} a_ o
F cc " } 0 a3
cc a.
W U
a_ o
o
CC
a } /\.
a W
3 pJq
kil
^ U
x \` r J
aCL
1p v a
a
U
', W O I- 4-4 41 Z
b1y Z � w Z
��ti Y J o Q A cm
o
xi
Od, N
IP ��
OJ
,,9 `II .»
b2
k
Z 1.4
z ctl
Q CO •If
O. a —
4 I... N
Z a m r.-
O W c
R. —1ict a. c d
m to
O N o E
—t