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HomeMy WebLinkAboutBLD2005-00665 lit UILDING PERMIT APPLICAAON MLA05-00619 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00665 Received Date: 10/19/2005 SITE ADDRESS: EAST QUILCENE RD QUILCENE, 98376 OWNER: SEAN E MCCARTHY PHONE: 360-990-4611 BRENDA MCCARTHY 2215 NW MULHOLLAND BLVD POULSBO WA 98370 QUILCREST VIEW TRACTS SUBDIVISION: Block: Lot: PARCEL NUMBER: 701185011 Section: 18 Township: 27 N Range: 01 W CONTRACTOR: REALITY HOMES INC PHONE: (253)926-6330 1308 ALEXANDER AVE E FIFE WA 98424 Contractor's License REALIH19840N Expires 2/15/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI NSFR W. ATT GARAGE TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 2,100 VALUATION 229,367.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: 2,100 #OF STORIES: 1 OCCUPANCY: OTHER: CONST TYPE: 5-1HR GARAGE: 484 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 2WELL BEDROOMS: BATHROOMS: Exist: 3 Exist: 2 Prop: 0 Prop: 0 A P P R O V E Total: 3 Total: 2 Routing Date: V( ©S DEC 30 2005 Jefferson County Plapninq Type Amount Paid By: Date: Receipt: stio ; 4e4f3Anerit Potable Water Application $53.00 SLE 10/19/05 77167 State Building Code $4.50 SLE 10/19/05 77167 0 5 0 1 4 Plan Check $1,119.14 SLE 10/19/05 77167 Permit $1,721.75 SLE 10/19/05 77167 JEFFERSON COUNTY 14' Total: $2,898.39 d • It BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD05-00665 Received Date 10/19/2005 SITE ADDRESS: 1223 EAST QUILCENE RD Issue Date 12/30/2005 QUILCENE, 98376 APPLICANT: SEAN E MCCARTHY PHONE: 360-990-4611 BRENDA MCCARTHY 2215 NW MULHOLLAND BLVD POULSBO WA 98370 SUBDIVISION: QUILCREST VIEW TRACTS Block: Lot: 11+ PARCEL NUMBER: 701185011 Section: 18 Township: 27 N Range: 01 W CONTRACTOR: REALITY HOMES INC PHONE: (253)926-6330 1308 ALEXANDER AVE E FIFE WA 98424 (253) 926-8515 Contractor's License: REALIHI984CN Expires: 2/15/2006 PROJECT DESCRIPTION: NSFR W. ATT GARAGE CALL IN FOR THE REQUIRE INySPECT ONS THAT APPLY TO YOUR PROJECT. SETBACKS:: �k Z 271 ab 4 UFFER: /VOttar Footing: 2/27 OG,�j J� Foundation: Ok 3 2 4714 (!' S L4ilb` V t,s41A-e9-A1,a.a.(411-'Lb Stormwater FINAL Approval: 44 r./zl /o;' t Underground Plumbing: Underground Insulation: Shear Wall : L:Xt Hic Alt cA 7/JOG Sheathing: Framing: ll _uaiiviAvrDAurtuc)lNKl/7/oG24-- wfrc..&ô k tk-9/9 7-31-(10 . Plumbing: Vttec, ., )- Ib' aG Lib Propane Ta/rtLines: p Insulation: - a-f4�Uh /v,MC 41 '4U'ut> hrAkt , per' �(4, 1 1-1#J.-o J.)-ASheetrock: oLISE /).vc-Y Dk A/24,Z, Septic Sytem Final Approval (If not on se er): Road Approach Final Approval: Zoning Final Approval: Final/Occupancy Approval: <T)K -i cr OA, 7/2-1/47 4/ HEALTH DEPARTMENT AND PUBLIC WORKS 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. HOT LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY - SEE REVERSE S SPECIAL CONDITIONS FOR CSE A BLD05-00665 1.) 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. 2.) 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. 3.) 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." 4.) All construction activities shall not encroach upon the stream and landslide hazard area buffers. This includes the storage or preparation of materials. 5.) 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. 6.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 7.) The identified Fish and Wildlife Habitat Area (Type 5 Stream), shall maintain a vegetative buffer setback of 50 feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to the proposed single family residence w/attached garage. 8.) An additional setback of five (5) feet is required from the edge of the stream buffer area to the proposed single family residence w/attached garage 9.) A permanent physical separation along the boundary of the stream buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 10.) Stream buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer - Do Not Remove or Alter Existing Vegetation." 11.) 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. 12.) A Stormwater Site 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. 13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 14.) Not more than two (2) unlicee d or inoperable vehicles shall be stored on any lot less than one-half acre 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 Unified Development Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable 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 of the UDC, and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area (ESA). 15.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 16.) The building height is not to exceed 35 feet. 17.) 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. 18.) 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. 19.) Minimum setback fro East Quilcene Road right-of-way shall be 20 feet. Minimum setback from any ingress/egress easement rights-of-ways shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. If in ESA is present, then the more restrictive setbacks shall apply. 20.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. I:\F_BLD_Permit_Buildng.rpt 10/29/1999 : . __. __. ,_ 4''. N (36.4. JEFFERSON COUNTY OCT 1 9 2005 ti s, , 0.4 DEPARTMENT OF COMMUNITY DEVELOPMENT j '*}� 621 Sheridan Street • Port Townsend • Washington 98368 q�, ��Q 360/379-4450 • 360/379-4451 Fax i $ING http://www.co.jefferson.wa.us/commdevelopment/ —`m STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# (, $-.)r L I t t PROJECT/APPLICANT NAME: -SE0-11 4. A3`l`€1 ` `& MC ,i r f ici Li .1 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. ParL SC.c Cfe a I c i'rl (c )t_1/ti 2Y1,J Lb r. Z/6C ,; ^-t-. h Oi,t.S( L i a' it lleti Ft el -1 ft.Vi e_ I- r 4—i cacti( el c[Li i'c LC)C., 1 - e_et/'C. {,tit 4 L{Zi i')a Fi /r/1 p4:te/' .f i i-z'i,c':-- Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. thltii•/41 WCCc t&C71 GtttCL . SI(Ili 4' 9icte-le- . -fits (311 '01s/G1c. (6,1t c -ll (- , aS i/-el%Ca1Fcy or) S'f /e tyk-Lp t{- t�n it. ClY) t r • 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. q.Y elj Siial f'iCCV-''I( , CC Liar 1 iL;Ile- , 'l((('i`'l1'Cr.t-Ili `::cc( i ct, l�ia c.r,hefrit,5� i t)I% 1i 'ry ti I S - fi iJ> atddtr 4. Describe the existing soils. Indicate soil type on the site map. 'COc__la5 . C.t.0 la 7 Sit 1 I V) pfl ft; 1{7C/ ca.min f-;',h . 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 acreal a of}each. j { �1 j��y j y 5 -c is no J)I,!1 S f�( St Hai-to 4.4 / YLiii oEf t.L,l)i alL(1 . 6. Describe any excess levels of noise generated by the proposed use or activity: 4 tI LlCkS {i1 .k Ii ] ,S61.j 2/(e.S i'1F.t_f11i1�iC . , , P Q'YED ( kUttechi1 j /C.ka- i-1 ' STORMWA`� ,� TER PLAN Stormwat B P;) r OCT 2 5 2005 stormwater site plan template.doc—rev.10/12/2003 Required JEFFER •• U Y DEPT.OF • 1, 'IT DEV . OPM_N SIGNATURE: • 7. Describe significant geographic features and critical areas (i.e., environmentalt1 set) itive areas such as wetlands, streams, steep slopes,etc.)on the site. Indicate location on the site map. I OCT I 9 2L. • 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.). • 5: 1- G , �i# ty_L5 ti���1 �� ��� ( w)CCt7_ '-it t M �t tlk I dtaf cr-t i{-1'1 c_ F E t Ir116v]t- r`M^ l Z i t IC cf t iM it' S t (r y f tu,Lk.tltt-st> 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. 9. 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. L-i }Tkiti L+( ( Ilk -Gill CfI i-t� 'c1` , /; ..t7/01 i�je b/er.s I f� 1U"tik.0 t 5\1-ST �c _�*-(V '} Li. 1 br i? lc !r`1 (J cc/ t (. I 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. 'VA:' Yb1.0. )C �c (; CU-la S }z: lack ct j' { ti (31,/tf s 12. Describe the flow control system. lU i =i-) 1 c L eA'11 t-,-C 1 S L S t i rs i.� f( l�a c t �kti e t 11 I Ice O�t r cif v-- �'�'1 ��i° '� L4: will v1[ itA.(4Li d 6v, Lr(t Jh _ ITRJJJ, (11(1` (Co r UCb d) ,ii)// ` , stormwater site plan template.doc—rev.10/12/2003 6 13. Describe the water quality system. 1,V ( / k.r 1z -j t --ti 1-)C,rrrit. / /0LA; Z;p `'?.ai`) fit/ `'DGk-CtC,Y` tC1/4. - 1 \ 14. Describe the conveyance system analysis and design. 0T192005 iy 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. 111,1 W l i c.l V'] U �Li �)`IC (:.:5 k_x i ri hi q '3 61 I • 6e x i (in c r FXC�' S S Zvi �1 �-► �( Sty-C_p (-- 1,r c.)/ l jcl-i10 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Urn orm Building Code. ?tCCCI1'1r' f o[- ct i( t hLi P�(c'c2i1Ct hi---e ls,�I/1 C 60-� f-r—ze ( t ri 17. Describe the proposed surfacing material. -lloh n cJ (Tc. i ! 4ti►1 91-41S S VCctirk9 , 18. Describe methods for restoration of the site. O(.ttIf C 1GL(, ct I���'t,. / 1"ia(4.t. = if3iiiic) in /I z 1 (fi f tY /at /) • 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. ,( 6 4- 20. List here an 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. stormwater site plan template.doc-rev.10/12/2003 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 thf-Construction SWPPP elements has ben 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 section 2-s.5 -of-Me-Manual (beginning*page 2-15). 12 Required Elements— Construction SWPPP OCT 1 9 2005 1. Mark Clearing Limits. 2. Establish Construction Access. C1(. ,S 114 tj I n LACC-N_SS k l i 10 On it'll f ,C v 1 tf t f c-. - 3. Cogtrol Flow Rates, (7r AA!e l 01 ftr trrn 4. In tall Sediment C trots. • C--Tral;e.I l ter` i ''fy1 . 5. Stabilize Soils. �Ct i C,CcIG�+��S , a/d e �'s . f�c:t . c i 3e( c'cu{)ci,ini 'Jj oY7 _zNitvx u1j C� `ZS'hu -h t�) , Lz t' - piCi17j _ ��� �li1.j S� fc 3 6. Protect Slopes. k Y cot_ ` of t� 1 Axi {ttfl- t- I nr?s _ `=4L tk�( ue >YtS iekiL ) ,, /1 i(toi <tiffit 9 7. Protect Drain Inlets. kle 01 I i t 0\ca Ur(c t-z t-k et k i)p i r1 k.t- area - i f) a CC,c,Vic. )C _. C.:7.2-(. Table q. stormwater site plan template.doc—rev.10/12/2003 8 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. AC C.--tyii 1I1 t 1 S C r1 1 e ' - OCT 1 q 2005 9. Control Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). P d It c;,JiFr, 6-!-1m, i' fi L S L /2.--7>7,: /AIF _rr7,.-r• ,•t 4iltj /2 A- itt >`i t r71 iZ lc.y u/r[l L-O,Y 11 Maintain Best Management Practices(B Ps). • .Qt%� C�/ti_ t ifl 13 rtr�t if he3 0 c-ki.z 4..j f (`( Y1 p/th'c/ 12. Manage the Project. • e c_ tL E t'1 (>1-1 bi '�,i:e( t /y , C. I mcce.1 het'S1s ehc .sk 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, roads). . b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). A. •tic) 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. stormwater site plan template.doc—rev.10/12/2003 9 I b. Description of special requirements for working in or near environmentally sensitive areas. OCT 1 ,t 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils( .g., erodibility,settleability, permeability,depth,texture,soil structure). N f-1 C;I( Lj .jr>� �� {� ;1f1C. ( y"z�,i c';1 `1ic(� Id �i'/01 ,�jt; e{ ;1 �(' �41t _ �(��r1(ki7 5t'f� `iurle.i-e_ SC{:j"►c. �� -�: �jc_ �IC{�(��! , `�1)GJ- : (ire_I�Yi:�21s 1 -1A* t << �tii��a1:�(� Yii--t lit Ci Cc:{ f.a \ . C�f; � �Ctr 111 I'S 01, 41� 1c t.�-jt , het i Irt t' t1 :�r �@ r 6cr I is `Milt 5. Construction Phasing. a. Construction sequence Y1- • '\,( `r1G�fh �l > �; II( ( ( ))�{ C VT,.(,:St: f-r: (+V . h—/.1 Kcr.) )Chi f--rtole-` I11(2. f°, /-e t r l" Y b. Construction phasing(if proposed) <J 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). Provide a proposed construction schedule. II. Wet Season Construction Activities. a. Proposed wet season construction activities. 1)‘(`' i( 1Cj 4 1 7 l'1C-I,'2li)0 i �u'�)iY lY� wr b ti `� {Ltt X cCk t" ) x r b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the property pwner responsible for the initiation of bonds and/or other financial securities. x'( a1 r)ria ktc ( [1.1tI 1.Li . b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. t.SC ( ( (Crk: t iri.1C:' )eY1 i11-S 16tri,) 1CrS .1 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following, if applicable. a. Sediment Ponds/Traps. b. Diversions. c. Waterways. d. Runoff/Stormwater Detention Calculations storrnwater site plan template.doc—rev.10/12/2003 10 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, 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 affected property. 2750.31'455{ (LANDOWNER OR AUTHORIZED RE TATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 1 1 1 stormwater site plan template.doc—rev.10/12/2003 12 • • 4�.�,gON co, JEFFERSON COUNTY { ,! � 1 r ! � Vi [�_> [ �1 W I j DEPARTMENT OF COMMUNITY DEVELOPMENT i . \ !I ` t '' , ; '� 1 621 Sheridan Street• Port Townsend • Washington 98368 ' i C 1 ! ; 1 I ' OCT 19 2005 ; 1 360/379-4450 • 360/379-4451 Fax ,_� ***Is, (cp' www.co.jefferson.wa.us/commdevelopment I ING ,, - Master Permit Application j r f !_ _ ~ (::`. Project description(include separate sheets as necessary): Tax Parcel , Property �J Number: �WI-16 560 Size:6 a-✓C_S (acres/square feet) Site Address and/or Directions to Property: '(f► ) r Li.,i icc'nc - 0 i•l5 mifrsi fW,.vi pc tq Fii// fC'9/ . Property Owner(s)of Record:PI ' I-' Avvierscri Telephone NO) 17(6j5``xY7 c) t Fax: ,i,) i A email: Aft/,- Mailing Address: ' ().:1�t) C (j j b'() / fti A '1&3 7 V' _ Applicant/Agent(if different from owner):SPOL41 r . . i3,-flcir4 A . I�L ea/"{-Gl y Telephone0K)&?7"2!3 j Fax: All > email: -Al I t. Mailing Address:JZlfi JUI,V M t 1I- iti,ne/ 6VOL I?"jL/.s;b,G , IA/A 9-3 1 o What kind of Permit?(Check each box that applies) Puilding ❑ Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** XSingle Family_ ._. 0 Discretionary"D"or Unnamed Use Classification A Garage (Attached)?Detached ❑ Special Use(Essential Public Facilities)** ❑ Manufactured e ❑ Boundary Line Adjustment Li Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** XAddress i Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** J Propane ❑ Plat Vacation/Alteration** ❑ Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** j(Stormwater Management Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive'Plan/UDC/Land Use District Map Amendment ❑ Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *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 Sv ot:✓4 ?rr At o ,M i•4 e r rFY to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE /�"�-,'+-� / L Date: 27 S'=i'-e', 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 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 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.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: F, 2 Date: /3 y;,r'`pS-- 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 responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and and dates it below. Signature: Date: t 1 5 q i' S C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc • o ,--- - -- -- - ----- --. -- 1 , ___ ____ , , OWNER BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,tha they aie notOlaedlogtraand khat they will be assuming the responsibility of the General Contractor for the proposed project. i Signature: Date: P S i I:'�0 j� L_. GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ,eal •rRoil? �� hi( , (2f 3) s2 — G.,330 (233)t2t,-, --Sz. 5 / EMAIL: N AILING ADDR S: r i A. CONTRACTORS LICENSE , ti.'A e.:114I„?y WAINS NUMBER: 1 E4 LO-, OP/ C n/ NUMBER ARCHITECT/ENGINEER: A9 1, Crle ifl1t-Gr11'7% IFY. PHONE ( ) ) S'S �c�c Ax;(25.3 )05-) r MAILING ADDRESS: 2' ri o 1 Ja A up AAA;A 'Si-e A- 1 EMAIL C-i j Hai i-130y i„/,l 4 (if.3.3r Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: X New `/` Wood Existing: E Sewer ❑ Addition 0 Steel Proposed: k' Bank ❑ Community System Alteration/Remodel ❑ Concrete Total: Height: Individual System F. Repair ❑ Masonry A -4- SEP Permit # C^-:, -7 Z.41, C=k)!',II,C 0 Demolition ❑ Other: Bedrooms: Water Supply: Pp Y: Existing: 3 Setback: ❑ Private well X Two Party Type of Heat: Proposed: �� ❑ Public >-�C. � Total: �� 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: 1 Heat Stove 1 Cook Stove 1 Woodstove I Fireplace Insert I Hot Water Tank i Pellet Stove I 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 For Office Use Only Current Proposed Amount Main Floor Consistency Review: 2Nu Floor Base fee: .� f?ZI. 75 3fd Floor Additional Section: ,,. Mezzanine: Plan Check fee: A, t` (q r Li Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated 911/Rd Approach fee: 7 ` Garage/Carport ,1;g ,/ a7 r TOTAL: $ 3 �-r:r 0'7 Decks c-----,----- Receipt Number: " 11G-1 Other �, `ucy- '7 `Cash/Check • Number: © t 1 _ ESTIMATED COST(REQUIRED) Date: > /i,�r 'Fair market value of all labor and materials foundation to finish (1 Il --I , 0 ) Initials: WO C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc