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HomeMy WebLinkAboutBLD2010-00218 �41$oN co& JEFFERS'COUNTY • 4 ' e DEPARTMENT OF COMMUNITY DEVELOPMENT I ~' ` `4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �.qs, 0� www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: 1 O"r t-1 Project Description(in cl ide separate sheets as necessary):�G/ I5(/) 1�( l'-✓C/ 6,,�i rA7t✓ /IA/A /fedl(� /4 P1 vr)-,h N7 Tax Parcel Number: 9/7/ - gar, - g-p / Property Size: P Y /$jam 2_2_ (acres/-quare fe- ) Site Address and/or Directions to Property: 973 o, K1 � 0 . forfi RAJ J K w,s- 93977 Property Owner(s)of Record: �C-Dh e r-± J.4cj< r4,,,,/ Telephone: 27/-Q 5 7-7 Fax: email: Mailing Address:4Q ( x .5 H Pa r-i- A . I n l< Applicant/Agent(if different from owner): S ` e r), f- Telephone: s'c 7-''7-/2 I Fax:360 •427 -t.:-._' email: 1'''IA)e.,*"t e iii...y.co m Mailing Address: 1 Ia )`a ry . �--v ) - -j (it�.0_ ?•3� - Whfrt kind of Permit?(Check each box that applies E uilding ❑ Critical Areas Stewardship Plan ❑ Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use) ❑ Single Family Ef Garage Attached 4t!stje. 0 Conditional Use[C(a), C(d),or C]** ❑ Manufactured Home 0 Modular 0 Discretionary"D"or Unnamed Use Classification ❑ Commercial* 0 Special Use(Essential Public Facilities)** ❑ Change of Use 0 Boundary Line Adjustment 0 Address 0 Road Approach 0 Short Plat** ❑ Home Business 0 Cottage Industry 0 Binding Site Plan** ❑ Propane �!i' 1 6 2010 0 Long Plat** ❑Sign 0 Planned Rural Residential Development(PRRD)/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 **Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, if known: n , DESIGNATION OF AGENT I hereby designate-u„v�x Li W'I Airy f}r 5 to act as my agent in matters relating to this appli Von for permit(s). OWNER SIGNATURE I N WA•k, Q:-.: ' Dater : 1 By signing this application form,the owner/agent attests th t 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 Cou ty in writing at the time of the ap t' f t the or she '- is prio otice. 44 Signature: . NCB � Date:t` The action or actions Applicant will undertakers 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-Iran-i` •1 onsibi ity dherin a d complyin the ESA. The Applicant has read this disclaimerscla and sign nd atte it below. Signature: v Date: \`t\ �� J�'� G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc • BUILDER STATEMENT • 1 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: �SF,N CONTRACTO R MANUFACTURED HOME INSTALLER: PHONE: FAX: sori"v" f3✓,' le)( invl� S pr (('c)) 2/Y7-/2( 9 ( )1j -72/,� .7,S y(/ e - MAILING ADDRESS: / ho,,,,,, ��•'1.. 1 i-,44)C'"SWAINS CONTRACTOR'S LICENSE NUMBER: -5U,4/GI b o2'r /I/ NUMBER 50407 ARCHITECT/ENGINEER: e rYe ��g PHONE (`�'�'" 6Z -.21/0FAX:( )77(-%$,S'7 MAILING ADDRESS: /2 6 L,U Co i urn�r, CF,v-t- EMAIL jaciliA.J (4)w_ 91 3J z___ Project Type: Frape Type: Bathrooms: Shoreline: Type of Sewage Disposal: er New ©/Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: e7' Bank ❑,Community System ❑ Alteration/Remodel ❑ Concrete Total: G Height: E 'Individual System .' ❑ Repair 0 Masonry SEP Permit# i' - 46 ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: O Setback: ❑ Private well ❑ Two Party Proposed: 0 0 Public Type of Heat: Total: T� ���N�_ Name 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: i Underground Tank i Above ground Tank Size of Propane Tank: i Heat Stove i Cook Stove i Woodstove i Fireplace Insert 1 Hot Water Tank i 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 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: rt3r 2' Floor Heated Consistency Review: Other Heated Base fee: 401 . Mezzanine Additional Section: Heated Basement Plan Check fee: �y ^ Q�' �1j71 !. rJv Unheated Basement State Surcharge fee: ��'`� Other Unheated Pot Water Review fee: 03 A)�,f- Garage/Carport SUBTOTAL ci 173 Decks 911/Rd Approach fee: Ei S,l Other TOTAL: $ q •--i Receipt Number: ( (1t 1 3 Cash/Check Number: 0 01 ESTIMATED COST(REQUIRED) Date: it market value of all labor and materials foundation to finish Initials: G:\PeunitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc h" 0 Efrt1'.4 .4"- 13y ROrof.rr .1 A e-k s. .,,� SounvcQ r 0) ` ;,x) S�s �, Y. S LEGEND _ 3S `I (, ( -.vrn di r . 973 OAk 13Av Rik 10' No Build t'+. fi A1oc k w ". 9 Y 3" P-1. i/Pla...) w�. 4s�3rr SCALE: 1"=20' Soil Log y�Arc e( * 93 l ., gvo- $o 1 7G�o , 3 -,_ 121.q THIS IS NOT A SURVEY ———— Budding Envelope Setback --'— Existing Componet • <.; ; Tree 'I08' • O, Property Corner — -- and/or Elevation (A) Clean Out ' 1- r (B) Septic Tank (C) Filter Sock (0) Pump Tank _ (E) D-Box 0-r S ID- - r I `�i ?i5 i 10 b-SC•)41cxi —lam IncLf- val . n COVicinity Map ir i 1 Vet Clinic 6 O.) • 11 S� EL 0 ?..] x 'Jni NCSD sign Q dy�a 9 . 1_ 1 � yg I 100% Primary Area (41 50' Laterals 9' O.C. ll a; i ACI; .Q•_< A git—1 , 8 _ -., --- idi --�i /—„'' �-, ;;,_I A,fa t� _ *0 o Build '40 #„I A ki . . , &, ---------2-°4-=: • I o E •I�ii °i ♦♦ SL 3�, 41 100% Reserve Area A \ , ' 7rt _D ,SL 2 A. '4/ ' 4 • ::\ c?j, . 0 Rcy EL +2 Notes: 1 ) Waterlines to maintain >10' from All Septic Components. 2) The Pump Tank & Controls will not be needed if the House Foundation is Tall Enough to Make Gravity. c;^ , Zif 1