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HomeMy WebLinkAboutBLD2010-00174 SON c'pG DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 -< Tel:360.379.4450 Fax:360.379.4451 Web:www.co.jefferson.wa.us/communitydevelopment -95.111 NOop E-mail:dcd(alco.jefferson.wa.us CERTIFICATE OF OCCUPANCY PERMIT#: BLD10-00174 APPLICANT: STEPHEN F PETERSON PHONE: 206-933-8678 7558 44TH AVE SW SEATTLE WA 98136-2202 SITE ADDRESS: 271 S BAYVIEW DR Issue Date: 01/10/2012 PORT LUDLOW, 98365 Final Date: 11/17/2015 SUBDIVISION: 9708- MATS MATS BEACH Block: Lot: PARCEL NUMBER: 970800329 Section: 33 Township: 29 N Range: 1 E PROJECT DESCRIPTION: NSFR W/ATT GARAGE &A/G 120 PROP TANK - REVISION 7/20/11 REDUCE SQ FT OF SFR THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2006 EDITION. OCCUPANCY GROUP: R-3 TYPE OF CONSTRUCTION: 5N SPRINKLER SYSTEM yes o THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 11/17/2015 Building Official, \\tidemark\data\forms\F_BLD_Occu pancy.rpt 11/19/2015 Je-iferson County Building Dion Permit NumiT` BLD10-00174 Applicant: PETERSON BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2006 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 2 IOW 01 i () ie-S-e_ .,-, 4_-_,, =4 Erosion Control 1------a)- ( _t �0-D Foundation Footing L/ ( ,(2- l /' Footing Drains -75- -0_ Foundation Stem Wall /5©// �---7 Underground Plumbing �).-I�I2......,_ `2q(1iu 417- r 4-_ a c, c. 2`/Z 3 Under Floor Framing /� Straps(hold downs) ---___________` Ext. Shear Wall Nailing .- Zi IC 1 Z C- Rough-in Plumbing _1 j ` l_l-i`-12 e6 Framing J -4- 116-R r& fitcrking— Airseal �`/b //..3 ))-_,_ Insulation:Walls I Sh3 Insulation: Floors S- -.0 ,(2.- %`)13 AZ-_ 7G, 5 f i Insulation: Ceiling 2/L,/!3 �-- Int. Shear Wall Nailing _. 1 Wallboard Nailing Gas Line: Interior1-e f -----.....------,' /9-c- Gas Line: Exterior i..7 1112/15 Ski Propane Tank %i/i?/;5 Uy Heat/Chimney Clearance i)„i 13 Drywell/Alt Drainage Address Posted ///l 7/t J y�i " I. C Ce-Ita -t*R RUX___ ; r " ,IS D sCi_lytrilk--7 t+ltx__ Gina 9 FINAL INSPECTION ii/t /t f" //;f' • FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR *l MLA10-00204 LDING PERMIT APPLICATIC�J Review Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD10-00174 Received Date: 5/25/2010 SITE ADDRESS: 271 S BAYVIEW DR PORT LUDLOW, 98365 OWNER: STEPHEN F PETERSON PHONE: 206-933-8678 7558 44TH AVE SW SEATTLE WA 98136-2202 MATS MATS BEACH SUBDIVISION: Block: 3 Lot 29 PARCEL NUMBER 970800329 Section: 33 Township: 29 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: ANN BEEMAN PHONE 206-448-0553 3827 B S EDMUNDS ST SEATTLE WA 98118 PROJECT DESCRIPTIOP NSFR W/ATT GARAGE & A/G 120 PROP TANK - REVISION 7/20/11 REDUCE SQ FT OF SFR TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION 200,000.00 MAIN: 842 CODE EDITION: 2006 ADD'L: 427 HEAT TYPE: EEE OCCUPANCY: R-3 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: 5N OTHER: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: 554 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: AA350 BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 otal: 2 Routing Date: T --II Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $1,553.75 LYK 05/25/10 117758 Plan Check $1,009.94 LYK 05/25/10 117758 APPROVED State Building Code $4.50 LYK 05/25/10 117758 JA"! ID 2012 Potable Water Application $98.00 LYK 05/25/10 117758 Total: $2,666.19 Jefferson County Planning & Building Department 1111 OF CONDITIONS for Building Permit# :BLD10-00174 1.) Water line must be located minimum of 10' from sewer line. 2.) SEPTIC SYSTEM COMPONENT SETBACKS TO STORMWATER MANAGEMENT FACILITIES - Any stormwater component: dry well, infiltration trench/pond, foundation drains, or any other source of water that is upgradient(above) or on the same contour MUST be setback a minimum of 10' from any septic system dispersal area (drainfield) and 5' from any septic tanks. Any stormwater component: dry well, infiltration trench/pond, foundation drains, or any other source of water that is downgradient or lower MUST be setback a minimum of 30' from any septic system dispersal area (drainfield) and 5' from any septic tanks. Surface drainage, roof run-off, splash blocks, etc. must be directed away from ALL septic components.63The conditions in the CASP permit(CSP11-00006) apply to this permit. A BUILDING J/FINAL CERTIFICATE OF OCCUPANCY SHALL NOT BE ISSUED UNTIL A MITIGATION 4 )AS-BUILD HAS BEEN SUBMITTED AND APPROVED BY DCD. 4.) 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. 5.) 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. 6.) A Stormwater 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. 7.) A"Construction Drawing" Flood *ton Certificate was prepared by a licenscurveyor and submitted with the application. The Certificate identified the base flood elevation of 6.68 feet. The lowest floor of the structure is required to be elevated at least one (1) foot above base flood elevation or 7.65 feet. PRIOR TO FINAL BUILDING INSPECTION, PROPONENT SHALL PROVIDE THE DEPARTMENT WITH AN ORIGINAL"FINISHED" CONSTRUCTION" FLOOD ELEVATION CERTIFICATE THAT HAS BEEN VERIFIED BY A LAND SURVEYOR, ENGINEER, OR ARCHITECT AUTHORIZED BY LAW TO CERTIFY ELEVATION INFORMATION IN THE STATE OF WASHINGTON. 8.) New construction and substantial improvement of any residential structure shall have the lowest floor, including basement, elevated one foot or more above the base flood elevation (BFE). 9.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 10.) 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. 11.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 12.) Residential developers and individual builders shall be required to preserve shoreline vegetation and reduce the associated risk of erosion during construction and any future activity which may impact the stability of the shoreline. 13.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 14.) The building height is not to exceed 35 feet. 15.) Building setback from Bayview Drive is no less than 20 feet. Side setbacks are no less than 5 feet. Shoreline setback is no less than 30 feet. U.S.DEPARTMENT OF HOMELAND SECURITY ELEVATION CERTIFICATE FEDERAL EMERGENCY MANAGEMENT AGENCY OMB No. 1660-0008 :National Flood Insurance Program Important: Read the instructions on pages 1-9. Expiration Date: July 31,2015 SECTION A—PROPERTY INFORMATION FOR INSURANCE COMPANY USE Al. Building Owner's Name Stephen Peterson Policy Number: A2. Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Cdrripaily NAIL Nurr;"per 271 S.Bayview Drive City Port Ludlow State WA ZIP Code 98365 A3. Property Description(Lot and Block Numbers,Tax Parcel Number,Legal Description,etc.) Mats Mats Beach Block 3, Lots 29&30; Parcel Number 970800329 A4. Building Use(e.g.,Residential, Non-Residential,Addition,Accessory,etc.)Residential A5. Latitude/Longitude: Lat. N 47D 57.475M Long.W122D 41.188M Horizontal Datum: ® NAD 1927 0 NAD 1983 A6. Attach at least 2 photographs of the building if the Certificate is being used to obtain flood insurance. A7. Building Diagram Number 1A A8. For a building with a crawlspace or enclosure(s): A9. For a building with an attached garage: a) Square footage of crawlspace or enclosure(s) 842 sq ft a) Square footage of attached garage sq ft b) Number of permanent flood openings in the crawlspace b) Number of permanent flood openings in the attached garage or enclosure(s)within 1.0 foot above adjacent grade within 1.0 foot above adjacent grade c) Total net area of flood openings in A8.b sq in c) Total net area of flood openings in A9.b sq in d) Engineered flood openings? ❑ Yes ❑ No d) Engineered flood openings? ❑ Yes ❑ No SECTION B—FLOOD INSURANCE RATE MAP(FIRM) INFORMATION B1.NFIP Community Name&Community Number B2.County Name B3.State Jefferson County Washington 930069 Jefferson WA I B4.Map/Panel Number B5.Suffix B6.FIRM Index Date B7.FIRM Panel B8.Flood B9 Base Flood Elevation(s)(Zone I4300690460 B 6-19-82 Effective/Revised Date ZonAe(s) AO,use ba6s 6800d depth) B10. Indicate the source of the Base Flood Elevation(BFE)data or base flood depth entered in Item B9. ❑ FIS Profile ❑ FIRM 0 Community Determined ® Other/Source:NOAA tide data B11. Indicate elevation datum used for BFE in Item 89: ❑NGVD 1929 ® NAVD 1988 ❑ Other/Source: B12. Is the building located in a Coastal Barrier Resources System(CBRS)area or Otherwise Protected Area(OPA)? 0 Yes ® No Designation Date: 0 CBRS 0 OPA SECTION C—BUILDING ELEVATION INFORMATION (SURVEY REQUIRED) Cl. Building elevations are based on: 0 Construction Drawings* 0 Building Under Construction' ® Finished Construction *A new Elevation Certificate will be required when construction of the building is complete. C2. Elevations—Zones A1—A30,AE,AH,A(with BFE),VE,V1—V30,V(with BFE),AR,AR/A,AR/AE,AR/A1—A30,AR/AH,AR/AO.Complete Items C2.a—h below according to the building diagram specified in Item A7. In Puerto Rico only,enter meters. Benchmark Utilized: Property corner TMB Vertical Datum: NAVD 1988 Indicate elevation datum used for the elevations in items a)through h)below. ❑NGVD 1929 ®NAVD 1988 ❑Other/Source: Datum used for building elevations must be the same as that used for the BFE. Check the measurement used. a)Top of bottom floor(including basement,crawlspace,or enclosure floor) 12.83. ®feet 0 meters b)Top of the next higher floor 19.83. 0 feet 0 meters c) Bottom of the lowest horizontal structural member(V Zones only) . 0 feet 0 meters d)Attached garage(top of slab) . 0 feet 0 meters e) Lowest elevation of machinery or equipment servicing the building . 0 feet ❑meters (Describe type of equipment and location in Comments) f) Lowest adjacent(finished)grade next to building(LAG) 12.54. ®feet 0 meters g)Highest adjacent(finished)grade next to building(HAG) 11.19. ®feet 0 meters h) Lowest adjacent grade at lowest elevation of deck or stairs,including structural support 10.75. 0 feet 0 meters SECTION D—SURVEYOR, ENGINEER,OR ARCHITECT CERTIFICATION rt This certification is to be signed and sealed by a land surveyor,engineer,or architect authorized by law to certify elevation !-'V.j •., information. I certify that the information on this Certificate represents my best efforts to interpret the data available. -.: ; Se..0 I understand that any false statement may be punishable by fine or imprisonment under 18 U.S. Code,Section 1001. a`� f WAS-7/ O Check here if comments are provided on back of form. Were latitude and longitude in Section A provided by a . / ® Check here if attachments. licensed land surveyor? ® Yes ® No / " :)----- ..4, Certifier's Name Michael S.Szatlocky License Number c33834 'ill ,, ,-14 Title Owner Company Name Cedarwood Group Fti ,j ;'alert.0 Address 32 Southridge Road City Port Angeles State WA ZIP Code 98363 • .,K�•N AL Signature 7 11-3-2015 Telephone 360-460-1705 � FEMA Form 086-0-33(7/12) See reverse side for continuation. Replaces all previous editions. ELEVATION CERTIFICATE, page 2 IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt., Unit,Suite, and/or Bldg.No.)or P.O.Route and Box No. Policy Number: 271 S. Bawview Drive City Port Ludlow State WA ZIP Code 98365 Company NAIC Number: SECTION D—SURVEYOR, ENGINEER, OR ARCHITECT CERTIFICATION (CONTINUED) Copy both sides of this Elevation Certificate for(1)community official,(2)insurance agent/company,and(3)building owner. Comments Temporary bench mark elevation was established by Wengler Surveying,Inc.,as ppart of a topographic survey conducted in 2002. Building is on bank above the BFE and not within the A zone. k r kj Signature L Date 11-3-2015 SECTION E—BUILDING ELEVATION INFORMATION(SURVEY NOT REQUIRED) FOR ZONE AO AND ZONE A(WITHOUT BFE) For Zones AO and A(without BFE),complete Items El—E5. If the Certificate is intended to support a LOMA or LOMR-F request,complete Sections A.B, and C.For Items El—E4,use natural grade,if available.Check the measurement used.In Puerto Rico only,enter meters. El. Provide elevation information for the following and check the appropriate boxes to show whether the elevation is above or below the highest adjacent grade(HAG)and the lowest adjacent grade(LAG). a)Top of bottom floor(including basement,crawlspace,or enclosure)is 0 feet ❑meters 0 above or 0 below the HAG. b)Top of bottom floor(including basement,crawlspace,or enclosure)is 0 feet ❑meters 0 above or❑ below the LAG. E2. For Building Diagrams 6-9 with permanent flood openings provided in Section A Items 8 and/or 9(see pages 8-9 of Instructions),the next higher floor (elevation C2.b in the diagrams)of the building is ❑feet 0 meters 0 above or 0 below the HAG. E3. Attached garage(top of slab)is ❑feet ❑meters 0 above or ❑below the HAG. E4. Top of platform of machinery and/or equipment servicing the building is 0 feet 0 meters 0 above or❑below the HAG. E5. Zone AO only: If no flood depth number is available,is the top of the bottom floor elevated in accordance with the community's floodplain management ordinance? 0 Yes 0 No 0 Unknown.The local official must certify this information in Section G. SECTION F—PROPERTY OWNER(OR OWNER'S REPRESENTATIVE)CERTIFICATION The property owner or owners authorized representative who completes Sections A,B,and E for Zone A(without a FEMA-issued or community-issued BFE) or Zone AO must sign here.The statements in Sections A,B,and E are correct to the best of my knowledge. Property Owner's or Owners Authorized Representative's Name Michael S.Szatlocky,PE Address 32 Southridge Road City Port Angeles State WA ZIP Code 98363 Signature Date 11-3-2015 Telephone 360-460-1705 Comments ❑Check here if attachments. SECTION G—COMMUNITY INFORMATION (OPTIONAL) The local official who is authorized by law or ordinance to administer the community's floodplain management ordinance can complete Sections A,B,C(or E).and G of this Elevation Certificate.Complete the applicable item(s)and sign below.Check the measurement used in Items G8—G10.In Puerto Rico only,enter meters. G1. ❑ The information in Section C was taken from other documentation that has been signed and sealed by a licensed surveyor,engineer,or architect who is authorized by law to certify elevation information. (Indicate the source and date of the elevation data in the Comments area below.) G2. 0 A community official completed Section E for a building located in Zone A(without a FEMA-issued or community-issued BFE)or Zone AO. G3. ❑ The following information(Items G4-G10)is provided for community floodplain management purposes. • G4.Permit Number G5, Date Permit Issued G6. Date Certificate Of Compliance/Occupancy Issued G7. This permit has been issued for: ❑ New Construction ❑Substantial Improvement G8. Elevation of as-built lowest floor(including basement)of the building: ❑feet ❑meters Datum G9. BFE or(in Zone AO)depth of flooding at the building site: ❑feet ❑meters Datum G10.Community's design flood elevation: ❑feet ❑meters Datum Local Official's Name Title Community Name Telephone Signature Date Comments ❑Check here if attachments. FEMA Form 086-0-33(7/12) Replaces all previous editions. ELEVATION CERTIFICATE, page 3 Building Photographs See Instructions for Item A6. IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt.,Unit,Suite,and/or Bldg.No.)or P.O.Route and Box No. Policy Number: 271 S. Bayview Drive City Port Ludlow State WA ZIP Code 98365 Company NAIC Number: If using the Elevation Certificate to obtain NFIP flood insurance, affix at least 2 building photographs below according to the instructions for Item A6. Identify all photographs with date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8. If submitting more photographs than will fit on this page, use the Continuation Page. , - 1 ¢V 1. , I♦„ :„...1 --- . ...,$„ • , C f 516.. = E. . MA- F ` wig r. 1L.� y J ' alit* al *4:!:= _,-,,„,,,5i' . ' ,,'4 ' is _.. v- Front of house as seen from northwest. Slab on grade construction. Photo taken Nov 2, 2015. r ti4 r� p p . • _ ". ' i.. South view of house. Photo taken Nov 2, 2015. FEMA Form 086-0-33(7/12) Replaces all previous editions. ELEVATION CERTIFICATE, page 4 Building Photographs Continuation Page IMPORTANT: In these spaces,copy the corresponding information from Section A. FOR INSURANCE COMPANY USE Building Street Address(including Apt..Unit, Suite,and/or Bldg. No.)or P.O. Route and Box No. Policy Number: 271 S.Bayview Drive City Port Ludlow State WA ZIP Code 98365 Company NAIC Number: If submitting more photographs than will fit on the preceding page, affix the additional photographs below. Identify all photographs with: date taken; "Front View" and "Rear View"; and, if required, "Right Side View" and "Left Side View." When applicable, photographs must show the foundation with representative examples of the flood openings or vents, as indicated in Section A8. i `.,. 1 ;; ?� s 4.. , 5. ' :gyp : f‘-:2?`"Vlit'1. 4,%4fi" 10' ...., ' '44/1444it.,,, 'is.: ' Y l \-t: `: d,' •,'gal ' z ii i "'PI :: .* e • • ; � t - � " .'- u to _y - ,r. mot ` ,s+ -460- z y J ..� � tt - - Rear of house as seen from southeast. 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VAULT 1:WELL �1_i \- I •t ..1864144.a.32 d�® C ' 3 g Iw ! r� ..g (74F -:- \ '1 29 1:Am 1 ; Q 271 _ \ s 1 I ;1 l �14 22'E /23.69" HOUSE I (n.) 101.61 Z N I g w CO{�gEp ponoi 208� i W I I W I I 11I I A ' c 30. I I �, \ LHlE IF MEAN HIGH TIDE i Iau 10� ELEV4TION=6.68 FEET(NCVD88) J 2 t.__. 7'FIR . i 1 a n. 31 I 12 8 HOUSE 0 6' HILLOW '' I_J 12 1 S 88'14 22'E !law42"FIR ' ' 1 — g COVERED PORCH h W z 32 c 17 s Iz — S 8814'22"E 112.39' ti tu N 22'47'38'E 13 70' YS n a 3 ri Jj . 9' ,��p MATS MATS BAY - .„soN co A* � JJEFFERSCWOUNTY S 4 DEPARTMENT OF COMMUNITY DEVELOPMENT 1 621 Sheridan Street• Port Townsend•Washington 98368 360/379-4450. 360/379-4451 Fax ��sQ$ www.co.jefferson.wa.us/commdevelopment IN 011 r� Master Permit Application MLA: i 1 0 V Project Description(include separate sheets as necessary): CE7A4s7- C7-/G1! ©,-" 4-/ -2c-2 Z ' 417 11-74:: Tax Parcel `l''":" • e0c7 - 33 c7 Property Number: 9v'� 3 Z9 Size: Z,3 S� S� (acres/square feet) Site Address and/or Directions to Property: VT-/ s V/ 1 e. /-r JL / c-L7, w, 7 `7,3&S Property Owner(s)of Record: S?&�'�/� •d'7' 1f7E7 -Sf%`../ /' Telephone:ZE7&o �33• c C' g Fax: -A-0/45/4 email: Qf 5cv1 e29; • Mailing Address: ,7-•S5 S 44 r�-f I9V ���L r G,,iq 3 /3 c . c, Applicant/Agent(if d• qn from owner): Telephone: 1.L )""d'j 65 Fax: 2 2. email: e (.4 Mailing Address: 3 •2 - P; S d . 'ri c%r/ 5 5f • j'/` _ c� What kind of Permit?(Check each box that applies Building ytei ❑Variance(Minor, Major or Reasonable Economic Use) Demolition Permit ❑Conditional Use[C(a),C(d),or C]*" Z Pc Single Family ❑Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home 0 Modular ❑Special Use(Essential Public Facilities)** ❑ Commercial* ❑ Boundary Line Adjustment O Change of Use 0 Short Plat** ❑ Address 0 Road Approach ❑ Binding Site Plan** Dome Business ❑Cottagelndustry 0 Long Plat** Propane 0 Planned Rural Residential Development(PRRD)/Amendrnents** sign 0 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)* ❑Shoreline Management Variance ❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* 0 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: DESIGNATION OF AGENT I hereby designate 4 '✓/✓ 6 1' to act as my agent in matters relating to this application for permit(s). C OWNER SIGNATURE ‘ Date: I Z — �,•C)( I By signing this application form,the weer/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 ter , 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 inspe``. . Staff's access and right of entry will be assumed unless the applicant informs the County in writing at the time of the applicatio at ,e •�,,41g•'!•• ••• ••lice. �� Signature: ti. _ 0 1/r,0 -, Date: 4, ZcO • 'C7 The action or actions Appli nt 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-transferab n ' 'r f adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below; Signature: • Date: -4 .ZCo - I U C:\Documents and Settings\carat\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc MAY 2 5 2010 • 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 assumi es n ' the General Contractor for the proposed project. Signature: Date: ' ' Z 5 ' ZO 1 -GENERAL.CONTRACTOR OR ANUFACTURED 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: p(New Wood Existing: u Sewer u Addition ri Steel Proposed: Bank Community System LJ Alteration/Remodel J Concrete Total: Height /a Individual System LJ Repair J Masonry SEP Permit# U Demolition J Other. Bedrooms: Wpter.Supply. Existing: Setback: Private well Two Party Proposed:Type of Heat - Pro p° J Public 7- (.-j- 7 I( Total: Name of System: If this is a Commercial Protect 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: WiII you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that ly: ❑Underground Tank Above ground Tank Size of Propane Tank ❑Heat Stove Coo Stove 0 Woodstove ❑ Fireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 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 property lines,buildings and septic system components, including the reserve area. Square Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH Bld App Review: '6N 2 1 ON, -1q{c-t r-3- i f 4 2na Floor Heated 1127 *00 2 I iCLL Consistency Review: n 13 '- Other Heated Base fee: �j Mezzanine /� grtd� ,rd,Sml,) p � Heated Basement Plan Check fee: Na K c . 14 — Unheated Basement Al/4State Surcharge fee: 54) Other Unheated �� Pot Water Review fee: Lap' Garage/Carport "/f� SUBTOTAL In Decks 334 7-z 911/Rd Approach fee: f `� f�sc L k 1SillL)� Other NrF TOTAL: $34S`7.I Receipt Number. 1 i V155 j72,4,,,,: Cash/Check Number ESTIMATED COST(REQUIRED) Date: l .Fair market va all labor and materia undation to finish - 5 35 10 �/ 20�,�� Initials: MAY252010 C:\Documents and Settings\canal\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc