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BLD2016-00401 - 01 PERMIT APPLICATION
•ILDING PERMIT APPLICATI• BLD16-00401 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD16-00401 Received Date: 9/8/2016 SITE ADDRESS: 2086 ANDERSON LAKE RD CHIMACUM, 98325 OWNER: MICHEAL S HENSON PHONE: 425-638-9816 MARY BETH HENSON PO BOX 398 Chimacum WA 98325 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901104033 Section: 10 Township: 29 N Range: 1V\ CONTRACTOR: TRUE BUILT HOME INC PHONE: 253-777-1714 2522 N PROCTOR PMB 32 TACOMA WA 98406 Contractor's License TRUEBBH925CD Expires 2/4/2017 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NSF SEP08-00030 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 884 VALUATION 125,000.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: SHORELINE: GARAGE: SETBACK: CONST TYPE: DECK: 112 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 1PWELL BEDROOMS: BATHROOMS: Type Amount Paid By: Date: Receipt Exist: 1 Exist: 1 Permit $1,202.00 SRE 09/08/16 165680 Prop: 1 Prop: 1 Plan Check $781.30 SRE 09/08/16 165680 Total: 2 Total: 2 Consistency Review $255.00 SRE 09/08/16 165680 Approved/Date Scanning Fee $21.00 SRE 09/08/16 165680 C State Building Code $4.50 SRE 09/08/16 165680 APPROVED EH SEP/RES Rev $129.00 SRE 09/08/16 165680 DCD Water Review $43.00 SRE 09/08/16 165680 C- L.ir, Potable Water Application $129.00 SRE 09/08/16 165680 Jefferson County DCD Total: $2,564.80 \\tirlom=r4\r1n4�\fnrmc\F RI fl Ann Rlrl rnf QIRI')(11F. • o Sally Ellis From: Susan Porto Sent: Tuesday, October 11, 2016 4:00 PM To: Sally Ellis; Emma Bolin Subject: FW: bid16-00401 is ready-SEP08-00030 Just an fyi on this case. See below Susaw Porto R.S. _)ef fersow Cou.wtj Pu.bLi.c H-eaLth Plnowe 3&0. 3859404 Fax 300. 379.4487 Alma s WorlziAA,P or a Sa er _ 1-feaLtinier e ersow Couwt any todisclosure,is or thdise sole use ofis the intendedprohibited. If you are andthe intended recipient, CONFIDENTIALITY NOTICE: This e-mail messagehorizdr including review,use,taclunents,is for the sole use the recipient(s) may contain confidential and privileged information. Any unauthorized please contact the sender by reply e-mail and destroy all copies of the original message. he Public Records law the County must release this e-mail and its contents to any person PUBLIC RECORDS ACT NOTICE: All e-mail sent to this r address has been received by the Jefferson County e-mail system and is therefore subject to the t whoPublic scoro a plaw found at RCW 42.56. who asks to obtain a copy(or for inspection)of this e-mail unless it is exempt from disclosure under state law,including R From:Susan Porto Sent:Tuesday, October 11, 2016 3:38 PM To:'Michael and Mary Henson' <mikrno@msn.com> Subject: RE: bid16-00401 is ready-SEP08-00030 Michael, w the reality is I should have required you to get a modification ermit for Howevee, Bence the sewer Okay; line to ensure the septic record is corrected after this essa permit rfall foria 4" diameter sewer at 1/8" designers are so backlogged and you have the necessary per foot, I will sign off this permit. BUT I will also put a hold condition on the bus bing permit requiring that you submit a revision to the septic system't was installed including bends and scaled drawing that provides what was installed, ho s cleanout locations, distance and fall and location of water line installation.the That degrees, prior to final occupancy drawing must be submitted, reviewed and approved residence. Please confirm this is something you agree to and I will proceed to sign off and add the conditions to your building permit. 5usain,Porto R.S. je=fersow cou.wtj Pu.bl,%c H-eaLtl' Plnowe 300. 3259404 Fax, 300. 379.4427 1 Mike and Mary MHenson On Oct 7, 2016, at 2:17 PM, Susan Porto <SPorto _ co.•efferson.wa.us>wrote: I have finished my review and signed off septic review. I think the permit is ready to issue. S Su.saw Porto R.S. Je-f fersow co tvttu Pu.bLLc H-ealth 448 Pinot/Le 30o. 3859404 Fax 3(00. 3t9. ALwa s Wori2%K' ora 5a er 1-fiea�th�er e -ersow cou.wt� he sole use f the CONFIDENTIALITY recipient(s) t(s and may contain confidential and privileged informatioe,including any n. Al for uauthorized ore review,use, intendedisr,or di () disclosure,or distributionis ie of the original me age.not the intended recipient,please contact the sender by reply e-mail and destroy all cop s has been received by the PUBLIC RECORDS and i th r fore subject tT NOTICE: toopth nail e Public Reco thisto s Act,asstate law found at RCW 42 Jefferson Und r the e- mail system a Public Records pa County must of this e-mail it is exethis mpt from disclosure under state law,including RCW 42.56. copy(or forinspection) From: Michael and Mary Henson [ „•,aiirn•mikrnoC�msn.com] Sent:Thursday, October 06, 2016 2:15 PM To:Sally Ellis<SEllistaco Iefferson.wa.us>; Susan Porto<SPorto@co iefferson.wa.us> Cc: Michael and Mary Henson<mikrnO m sn•com> Subject: Fwd: Invoice 2222 from Cleaver Construction, Inc. Please send/forward to Susan Porto. Thanx MHenson Begin forwarded message: From: Christoper Morton<chris • cleaverse•tic.com> PM PDT Date:Michael October 6, 2016 H Henson<6mikrn(a�msn.com> To: Michaela Y Subject: Re: Invoice 2222 from Cleaver Construction,Inc. Michael, Your report has been filed and locked. see attached. We moved offices and canceled Xfinity services. Thank you, 3 0..$ON ro DEPARTMEPOF COMMUNITY DEVELOPMENT 8`>a C{�' �r 621 Sheridan Street,Port Townsend,WA 98368 /1,:',./././ Tel:360.379.4450 I Fax:360.379.4451 ~' Web:www.co.jefferson.wa.us/communitydevelopment E-mail:dcd@co.jeffetson.wa.us SFA ./ SN I N C39 /'"' N.8 8 0 420 2012/2015 International Coc'&i�, Transition Request for Review Jefferson County will be transitioning between the 2012 and 2015 International Codes beginning July 1 , 2016. Many construction projects are in development for several months before the implementation of the new code requirements. Requiring applicant's to redesign their projects creates a hardship to the homeowner/applicant. Jefferson County will allow application for projects designed under the 2012 code to be submitted until October 1, 2016. During the transition period between July 1 and October 1 the applicant shall determine which code they wish their plans to be reviewed under. The choice will determine which building, mechanical, plumbing,fire and energy code will be referenced in the plan review. You may not switch back and forth between codes for the different trades. Once you choose a code year, your project will be regulated by this code edition until completion of the project or permit expiration date, whichever comes first. Projects received on or after October I, 2016 shall be designed and reviewed to the 2015 International Codes. A I, i I �- n-R4 J .)5OAlapplicant for BLD , choose to have my permits reviewed under the: (Check one) 2012 International Codes ❑ 2015 Inter ational Codes ,— `� Date // 26/6 6 Signature of owner/applicant For more information visit- http://www.energy.wsu.edu/BuildingEfficiency/EnergyCode.aspx Prescriptive Worksheet PDF.PDiehF Page 1 of 1 1111, • w Word Online fa,Save to OneDrivelir/4 Print JD Find r;Download ••• es Prescriptive Energy Code Compliance for All Climate Zones in Washington Pitirecr isSsimer.do Cried Inforrnetior. Michael k,i Mary Henson True Pint horny 2586 Anderson Lake Rd 2S3 777 1713 Chimacum liVA 98325 This project will use the requirements of the Prescriptive Path DelOw and incorporate the the minimum values fisted.In addition,based on the size of the structure,the appropriate number of additional credits are checked as hosen by the permit applicant. Authorized Representative Dale (.." ..... All Climate Lodes - — 1...7".... R-Value' U Factor' 0, Fenestration LI-Factor° WEI 0.30 Slcylight U-Factor nia ,, 0 50 Glazed Fenestration SHGC" Ma nia Ceiling 494 0.026 • Wood Frame Walli-u 21 int 0.056 Mass Wall RA/alue' 21121 0.056 ... . Floor 309 0 D.029 iii&....&.., ° e0/6 Below Grade Walt" 10/5/21 int.TB 0.042 °-'2ii 6.0A/ Slab°it-Value&Depth 10,2 fl nia Table R402,1 1 and Table R402.1.3 Footnotes included OR Page 2 -' COUIvri, • I - Each dwelling unit in one and tyro-family dwellings and townhouses,as defined in Section 101.2 of the International Residential Code shall comply with sufficient options from Table R406,2 Co as to achieve the following minimum number of credits: 01.Small Dwelling Unit 0.5 points Dwelling units less than 1500 square feet in conditioned floor area with less than 300 square feet of fenestration area, Additions to existing building that are less than 750 square feet of heated lloor area 02.Medium Dwelling Unit: 1.5 points All dwelling units that are not included in al or 03,including additions over 750 square feet 03,Large Dwelling Unit: 2,5 points Dwelling units exceeding 5000 square feet of conditioned floor area. 94. Dwelling unit other than one and two-family dwellings and townhouses: Exempt As defined in Section 101 2 of the international Residential Code Table R406.2 Summary Option Description Credit/s) is 'Efficient Building Envelope la 05 0 lb Efficient Striding Envelope lb1 0 0 .. . it Efficient Building Envelope it 2 0 D 2a -.Air Leakage Control and Efficient Ventilation 2a 135 0 20 Air Leakage Control and Efficient Ventilation 2b 1.0 0 2c Air Leakage Control and Efficient Ventilation 2c 1 5 0 3a High Efficiency HVAC 3a 05 0 30 High Efficiency HVAC 3b 1,0 0 3c High Efficiency HVAC 3c 2 0 0 3d High Efficiency HVAC 3d 1 0 0 4 High Efficiency HVAC Distribution System 1 0 , 0 5a Efficient Water Heating 05 0 0,5 50 Ifficient Water Heating 1,5 0 6 Renewable Electric Energy 0.5 11200 kwh 0.0 Total Credits 0.50 'Please refer to Table R406.2 for complete option descriptions 1,1 ' ..k.i 1 ' 'OA,.• .- . i• . ,' ..,1,A I• ...II, ,n• E4 zal.. .e .I.4,4 ..•• Jable R402.1.1 f 091.1101e1 For SI;1 foot.=304.8 mm,ci.=continuous insulation,int.=intermediate framing. 'R-values are minimums,U-factors and SHGC are maximums.When insulation is installed in a cavity which is less than the label or design thickness of the insulation,the compressed R-value of the insulation from Appendix Table A101.4 shall not be less than the R-value specified in the table, b The fenestration U-factor column excludes skylights.The SHGC column applies to all glazed fenestration, Exception:Skylights may be excluded from glazed fenestration SHGC requirements in Climate Zones 1 through 3 where the SHGC for such skylights does not exceed 0.30. V '"10/15/21.4TB"means R-10 continuous insulation on the exterior of the wall,or R-15 on the continuous PAGE 1 OF 2 HELP IMPROVE OFFICE 100% https://word-view.officeapps.live.com/wv/wordv iewerframe.asp x?PdfIVIode=1&ui=en-US&... 9/7/2016 Heat Sizing pdf.pdf • Page 1 of 1 • Word Online fa Save to OneDrive ilgt Print P Find El Download e Simple Heating System Size:Washington State This henna totem Mate calnetator 4a b the Pretedueve Reauke - at ste 2015 W Weatirititio.State.Enemy Cede[W EECE and ACCR.. ,�.,. r a _r The .- s-a• alt s.w I.�w sa#,+Y,,x': .^._ .;,n ar z <•s. t"m,.+c a+ n *z�un'... kw The gW11W9 twordwg and door amnion Cf Was caktEiatrOr/WWWWW the tnstatert Gam' $and roar Is haw an area weighted average U-tffCtor of 3.30 The wompmated tnerdetron reporrernents are the megawatt pressuiptspe amounts specified by the 2015 be'SEC Meese fiat out as of the green drophde re and Asa hat ere epplicable to deer project.As you rake selestmaa in the dropido r ee ten tech season, sore:asides rot be eakertated for you tf Yom`de not see the se yew need tar We alsodidawn optionsplease cat the VI/SU Energy Extension Pram at{354)W35,2042 tau aasastar=ca. i L_aFru utor st tiffarms bt-AMOTT ...- )#aetenft Seetent leer t+t s.k:, r.w*ten 7o oedemata instructews toroth seetrerr Moe morwoof on the eric"Nsa+toaeto". Peskin 1nmaeretur8 .t tir' ..�.mm`a�;-oaaaaar, r.e*raffia Area 04 Duitf+ng Conditioned Floor Area TETT".t. Condemned Row Area ICC tp Average Ceding Haigttt ��{ Gombioned Vckana a etiuc-..r-m-s Average Cabo*tie5td Of} r' ,i.xira`.1Iw! 7.072 Glazing and Doers U-Factor X Area = UA -+L=4.i 0.30 '1- Skaffa htg _Skafahtl U-Factor X Area = UA 0 50 kisutatlott Attie LI-Factor X(� ArusUS. • as era• r 4.0225 I S&3 22,g2 Single Rafter or„foist Vaulted Ceilings U-FactorXArea UA I Above Grade Wage nae neon t? U-Fasten X Area US eatrecleont ;LI tam • 0.058 Frw7EtiffiWil 42.35 FloorsU-Factor X Area UA Tej 4 425 I n i I 12.10 below Gracie Wads gone..is U-Factor X Area UA a a u.re op, 10, tte dWIWWW Stab HMow Gradelta v _ F-Fater X Length UA a es Ions ,F _, -^^-�— yw FtC neleetron Stab on Grade me p .. - Factor X Length US etre tw3en �- re Orrn • Ha ealecson Location Of Ducts ... ....... Duet leakage Coefficient tWWW.W.5uate W 1.10 Auer of UA 148.55 Envelope Heat toad C.t30 tOe I Hour Frg:cre t- ate,a`br.Xar Air tsakage Heat Load 3.437 6w I Hour saMtT tt UP a 01Z Htddirrg Design Heat toad t0 r22 Uta I Hear mown,: toe. r Building and boot Heat toad i t,134 S r Hour c, .firss.M.' 6etts ae...Manes VA. Cstale wee Lou Gate .f,neennerre nctee-S,.etc fl tee X' Matatrum Heat Equipment Output 15.587 ges t Hoer areunra,f t; +eaa sax•.:art r._xzr aarwsr COW. ams We 14..1 ft ron-err fir--. ... ...... HELP IMPROVE OFFICE 100%. PAGE 1 OF https://word-view.o fficeapp s.l ive.co m/wv/wo rdvi ewerframe.aspx?P dfMode=1&ui=en-U S&... 9/7/2016 .... , Glazing Schedule pdf.pdf • Page 1 of 1 • Word Online Save to OneDrive 0, Print .P Find r4.,Download ... Window,Skylight and Door Schedule C177 ,.+Vbra,54,0, Michael&Mare Henson true B61/Home 2086 Anderson Lake Pd 3403 N Provdor St Chirnacurn ,,,,A 00320 TerHena WA 98107 Width Height Ref U-factot Ot. Feet ''''') Feet'' AT ea UA Exempt Swinging Door(24 sq ft max) 0 0 0 00 , Exempt Glazed Fenestration(15 sq ft max) WSEC 3 1 3 '' .3 - 90 2 70 Vertical Fenestration(Windows and doors) Component Width He j11.* Description Pet U-factLto Qt Feet '' Feet ''' Area UA tt, 60610 GLASS WSEC 0 30 1 6 a 6 - 41 0 12 30 80610 SGEt temp ,At'SEC 0.30 1 3 ) 6 54.7 16.40 00 000 1030 HS lenio '77085rl L.0 1 3 3 3 :. 9 0 2.70 4750 HS 'etF,F-0- ;,1 150 1 t 5 - 20.0 660 ...... 5040 HS PtSEC t.3,7, 1 5 J 4 - 200 608 5050 HS temp W.0--;Er ci lf). 2 5 *3 ': €o..o 1560 0.0 0 00 ... 0.0 000 0 0 0.00 0.0 000 00 000 00 000 0.0 000 00 0 00 0.0 000 0.0 0 00 0.0 000 . .. 0.0 000 . 0.0 0 00 0.0 000 . . 00 000 0.0 000 8.0 600 0,0 0 00 0.0 0.00 00 000 00 1400 .., - 0.0 000 0.0 0.00 0.0 000 08 000 00 000 0.0 0 00 00 0 00 0.0 000 0.0 0 00 00 000 . ... 00 000 r- . 0.0 000 0.0 000 0.0 000 V PAGE 1 OE 2 HELP IMPROVE OFFICE 100% https://word-view.officeapps.live.com/wv/wordviewerframe.aspx?PdfMode=l&ui=en-US&... 9/7/2016 SON co °G,� "'DEPARTMENT OF COMMI�ITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 ~' `C Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.jefferson.wa.us/communitydevelopment O� E-mail:dcd@co.jefferson.wa.us =� S INGS ill 474 ? PERMIT APPLICATIO + SEp . � v Ste s in the Permit Process: 40/64 -Review application checklist to ensure all information is completed prior to subF1 licatiOri -Make sure septic has been applied for and water availability has been proven. lir C:®�iv. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. "7)% -This is not a standalone application;it must be accompanied by a project specific supplemental applion. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# , J Site Information Assessor Tax Parcel Number: ‘70/ IOL/ ®33 Site Address and/or Directions to Property: 2 0 6, /01NP� .1 4.1-k , 0-\A 71k--'i,4 C_U N\j u.J 4 c?F3 ^— Access(name of street(s)) from which access will be gained: A. A.) p,,.®iu 1....*k6 k( . Present use of property: : e-- S 6 + S1ZR c::----)-4--.1).- rSelsil 6) b e Description of Work(include proposed uses): 1J,S`f-, C.I.(2-'" I SA-rh % 51)Ry g&4._ ___„...<- r .74:—. Ho L 4'5E. Wastewater-Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: X Septic Septic Permit#: 4,= e Z - ; i)i 3n Community Septic Name of System: f_ m ^. 46 Case#: Are other residences connected to the septic system? ign Additions or repairs to sewage system: N/111 Is it a complete or partial system installation: Complete X Partial Has a reserve drainfield been designated? Yes X No Attach last report to Date of Last Operations& Maintenance check: 0 2U/ application Describe or attach any drainfield easements, covenants or noti e08 ,s on title, which may impact the property: Pcirnrt \pnlicstx>n Page 1 of 2 The authorized agent/representative is the primary contact for all project-related que 4 -'ns and correspondence. The County will mail /e-mail requests and information ab he application to the authorized agent/repr tative and will copy(cc)the owner noted below. The authorized agent/represe� tive is responsible for communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email(i.e., County email is not blocked or sent to "junk mail"). Applscant/Property•Owner:Information .•;* tis " m # „ x Property Owner: j -) /� l Name: / I i e_V1GV go MAP)/ 12• /Veit SCi"t-1 Address: +� & ,) �8 c- G, 1 AA a C u M , uJII- ¶7 3 Phone#: '(Z "" -3g 616 E-mail Address: `,.,1 ({k a.- NOJ Mme/ 0© ems Please contact a uthorized Agent/Representative with project info. (select only one). Property Owner Signature:AiiitQ4•►_ _4 _►lam Date: S I. 2®/ Note: For projects with multiple owners,attach a separate sheet h each owner(s)information and signatures. ppliCant ° u a iZe gent Represen a iVE' If.oth& hapainNnerj .x5 � , s Name: Address: Phone#: E-mail Address: 'P.rofessi©t;•-- :,..--...,ii; g„,. s T is an •ut orized '.`en -.11:60ort.is; ro ectr ?", 9 _ Engineer A Architect Surveyor Contractor Consultant Name: NZ. as. j '`�t e_ License# TSA E�B 1-5 2 SC Address: ZZ a /I roik S'7—, c 6 72------ z_ ` 1—Acele,Aq u)14 Phone Z.5-,3 Z."72. S3©0 E-maitddress: ) / Cl la4b Professional.i s'tthis an Author i ell/Representative for this''projei t•? 6 ,x $ a=y ' �, Engineer Architect Surveyor Contractor ✓ Consultant Name: M :- $ A 6(0o e- License# Address: I(-61 4 flo&e Phone#: E-mail Address: Prod ss ona - , s�ias 741"4•0„,. e i ,,` n%eP eftr forJrhi.. roJect? , Q� 5 Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: 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 or her 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I 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. Applicant may request notice f the C unty's intent to enter upon the property for visits related to this application and subsequent permit issuance. Signature: ,0:=5""( Print Name: akil 101Q Q/ /4 Date: g 2_Z /c 3'.n pit,=1ppiication Page 2 of 2 - . ' ][ OF COMMUNITY DEVELOMENT �w -� » , Sep RESIDENTIAL OR New I/ Replacement Relocated_ _ Addition Repair Demolition * *A separate permis required Select One: ' Single Family Residence 'w'/ Modular Other list Number of floors I #new bedrooms ' 405,c existing 0 total bed i 1 #new bathrooms / existing i total bath 2. Select all that apply: Electrics,X Heating Oil Wood Propane Enter the square footage(sq/It)that applies in each field: Residential/Commercial ,r::,;i4rf--,-:.:';''' -i.,,,',- ,-,,, i;,;., K8ainFloor �� ���� Residential/Commercial Second Floor Additional Floors heated/unheated Basement-unfinished Basement-finished space or habitable �� ���� Detached Garage heated/unheated ~~- �~� �- Attached Garage-heated/unheated GarageZndM unfinished storage Garage 2nd II finished space or habitable Carport 2 walls or less Deck-uncovered ��~� Covered porch ���� Other(shed barn pole bldg etc ) / _ Estimated Cost of Prject (Required): $ 515-ono �� I-� ��000 / ' List existing buildings on propert�e house garage, accessory dwelling unit,s d, barn, mobile home,other): ASI fx�stng Buildmgs'on Property r z Use ,..-` kI. ,;.� x 7��tycNEA f} W/ M,sa Abu _ R/1-EE �STe e pi I 9' Ar ` R 11E-L_ 7A/ler 5 tom, c_neak,� �� rr -sa^A *a 8 "�..�. "a� � `.`'�. •=asw �.� ",�"`:�;'3 .'x '�` '�`-� .�y, 'i �'�z3'f �� � °mow $` The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed contractors and/ that hey will be assuming the responsibility of the General Contracto for the proposed project. Signature: / A Print Name:M, )1l e) ek)... 'Date: V/t? ZOi� 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 or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this pplication packet may result in making any issued permit null and void. Signature' / Print Name:(0) ) e S Date: f7 ZO/C Itio �an r a- '.t iu . s B-igu '"€>^� a.� vgs,+30--.:, m4 r T rF '_^V.:;j ,'s" >" 4,,A;.,.`,\.a..a.> w,,,"S-w Building Permit Fees Building Base t 20 v Plan Check Review ;) 3Cr Land Use Review $255.00 Septic Review $129.00 Potable Water $172.00 Technology/Scan $21.00 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Total Fees Receipt# Date: Cash/Check/CC: Supplemental SFR SON r, DEPARTMENT OF COMMUNITY DEVELOPMENT - ��� o6 621 Sheridan Street,P ownsend,WA 98368 1--1 Tel 360.379.4450 I Fax: 60.379.4451 • = ;= -C Web-www.co-Jefferson-wa.us/communit<7development 4. �t E-mail:dcd@co.jeffcrson.wa.us t ee It H j NG SUPPLEMENTAL APPLICATIONst DETERMINATION OF ADEQUATE P LEVE . N Owner Name: Ml'Gicx elf f,� )a r- l Y si Parcel No. 8trN 0 3 Site Address: n water Source Existing Proposed : Attach Copies of 1) Well Logs Private well (if no log report on file,a 1 hr stabilization test may be substituted.) 2) Lab analysis tested within 3 years of application. Total Coliform, Nitrate N, Chloride 2-Party Well Items above AND recorded Operations&Maintenance agreement and recorded Easement. Alternative Provide justification and design per Jefferson County System: Environmental Health policy 97-01 www.jeffersoncou ntypublichealth.org/pdf/Policy_97-01_Ra inwater_Collection.pdf Valid Water Right Lab Analysis as required under private well above. Permit: Generally applies to springs, attach copy. Public Water: Name of Water Provider: -Submit Water Availability Notification form completed by your water purveyor. NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or unmaintained County road and/or Right-of-Way easement,then a Right-of-Way application will be needed. Resolution#99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings. 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this application will be performed in compliance with all applicable federal,state and county laws and regulations and I 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. Applicant may request notice of the County's intent to enter upon the property for visits related to this application and subsequent permi issuance. k , ` Signature: Print Name- C 4i ' ��SOa-bate: & 22/J / d«. Y FOR OFFICE USE ONLY 1) Water-RightPerttilit4t, * r - 3J IndividualWell n Y a * ��� fa r 2)Public Water Supply WS ID# Meets Water Quality Standards? Yes y No In Compliance Yes fVo `,WRIA 17 Subbasin SIPZ Coastal/Moderate,/Hh''ig � 4 *No• , used upon information provided bythe applicant at appears thatthe potable water supply ..' r --- b, x --" � $ - '�� -� , mss+, �.�,� �°� Meet :Conditionally-Meets - :- floesnot Meet ,s SON c (,--- ARIA . ° DEP ENT OF COMMUNITY DE LOPMENT ' j 621 Sheridan Street,Port Townsend,WA 98368 If--1-? "z -< Tel 360379.4450 'Fax 360379.4431 _ Web:www.co.Jefferson.wa.us/commumthdevelopment �1 E-mail:dcd@co.jefferson.wa.us Sr NG' o WATER AV :ILITY NOTIFICATION PUBLI ' ATER SYSTEM TO: Jefferson County Environmental He. h Department FROM: (Water System Name) System Operator: State ID Number: Total connections for which system is approved: Number of service connections existing(in use): Number of service connections committed: Date and results of most recent water bacteriological analysis: / / The water system is capable of and will supply potable water to the following location: Assessor's Parcel ID#: Legal Description: Site Address: Operator Signature: Date: / / EXPIRATION DATE OF THIS SERVICE COMMITMENT: / / SPECTRA Laboratories — Kitsap 0 , 26276 Twelves Lane,Suite C, Poulsbo,WA 98370 (360)779-5141 COLIFORM BACTERIA ANALYSIS c)Dat7e 7/ 2. Time Sample Collected County , JiAm Month Day Year 1 ':',7) : .7:1 0 PM :r Type of Water System(check only one box) r, CI Group A El Group B 40 Other Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): filtse(Colit . . ID SystemPerson: Send Name: Contact ) Cell Phone: e:( P .. 8 2018 Eve.Phone: Fax:( ) Email Address: Day Phone:( Send results and invoices to:(Print full name,address and zip code or email only) ...FTSON IN-A 1' a., ',..,,c,A. . , - ,,,,1 ... ,. L-4 ,,,,, c.,.., Ottivri, IC , .b_ .. ,..... • r rico A SAMPLE INFORMATION , / Sample collected by(name): ' i „ .,, , Specific location where sample collected: Special Instructions or comments: 9, ,. .. . .. Type of Sample(must check only one box of#1 through#4 listed below) 1. El Routine Distribution Sample 2.Repeat Sample(after unsatisfactory routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total Free 0 Source Groundwater Rule(GWR-R A/P) 3.Raw Water Source Sample (Population of 1,000 or less) 0E.coil—GWR(NP) Unsatisfactory routine lab number: El Fecal—Surface,GWI,springs(enumeration) — — — - Unsatisfactory routine collect date: Filtered Yes No 0 Assessment Monitoring(NP) / / pOther Temp Chlorinated:Yes No Chlorine Residual:Total Free I s I I I 4.0 Sample Collected for Information Only . Investigative Construction/Repairs Private Residence ;1, Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Analyst Ramarks: ... .. 0 Unsatisfactory Total Coliform Present and 0 Satisfactory CI E.coil present 0 E.coli absent Sample Rejected(no analysis performed): El Sample too old(>30 hours) 0 Low Volume El El Improper Container GHigh Chlorine(>15m / ) Bacterial Density Results:Total Coliform /100m1. E.co/i /lOOml. Fecal Coliform /100m1. HPC / 1 m. / Method Code: Date and Time Received: MICR-2720 ....._ Date Analyzed: Date Reported: Sample Number(DOH number plus five digits) Lab Use Only: 010 - DOH Form#331 319(revised 12/15) White-DOH Olympia Blue-Laboratory Green-Water Supplier Gold-DOH Removal • •CTRA Laboratories -Kitsap LLC • r 26276 Twelve Trees Lane,Suite C Poulsbo,WA 98370 Telephone(360)779-5141 FAX(360)779-5150 IOC - SHORT IOC-SHORT by Various EPA Approved Methods Source/Point of Entry-Report of Analysis Date Collected: 7/20/2016 Group: Private System ID No: Private System Name: Private Henson Lab-Sample#: 01071202 County: Jefferson Sample Location: Standpipe From Well DOH Source No: Sample Purpose: RC Date Received: 7/20/2016 Sample Composition: S Date Analyzed: 7/22/2016 Send Report To: Michael Henson Date Reported: 8/2/2016 P.O.Box 398 Sample Type: Pre-treatment/Raw Chimacum,WA 98325 Collected By: Michael Henson Phone Number: 425-638-9816 Bill To: Michael Henson P.O.Box 398 Chimacum,WA 98325 DOH# Analyte Results Units SRL Trigger MCL* MCL Method Exceeded _(Analyst Init.) , 1 405 Calcium_ _ 52.8 mg/L 1 0.05 L_____EPA_200._7_(KW)_ , 4 Arsenic — 0.0099_ _m L 0.0014 i_ 0.01 0.01 ______f_ EPA 200.9(KA/1 J 409 0- 7.26 P H units ___ r __ 1 =SM 4500-H+B(EC) 1 20 Nitrate-N 0.18 mg/L 0.5 5 10 ___1 = EPA 300.0(EC) r 21 Chloride 9.66 _ m.L 20 _ _ 250 EPA 300_0(EC) 1 1— --1 Iron 3.51 m L 0.1 0.3 Yes EPA 200.7(KW) 10 Manganese _ 0.604 ml L 0.01 0.05 Yes EPA 200.7(KW) SRL: (State Reporting Level),indicates the minimum reporting level required by the Washington Department of Health (DOH). Trigger Level: DOH Drinking Water response level. Systems with compounds detected at concentrations in excess of this level are required to take additional samples.Contact your regional DOH office for further information. MCL: (Maximum Contaminant Level),If the contaminant amount exceeds the MCL,immediately contact your regional DOH office. NA: (Not Analyzed),in the results column indicates this compound was not included in the current analysis. ND: (Not Detected),in the results column indicates this compound was analyzed and not detected at a level greater than or equal to the SRL <(0.00x): indicates the compound was not detected in the sample at or above the concentration indicated. * The 0.010 mg/L MCL for Arsenic is for Group A NTNC systems. All other systems should check with their county Health District to determine what level is applicable. II CIE . . I \' . .3 /313 . . ... A SEP - 8 2016 JtFF -wUNre pm 160712 i • No w o �f Intent /1 l ��� File Original with WATER WELL REPORT rL Department of Ecology UNIQUE WELL I D# Copy STATE OF WASHINGTON Second Copy Owner's Water Right Permit No Third Copy-Onllefs Copy J C I ? a-+ Address . $J �AJ1t/�Q/ /"/rte ,1. Pd ?S( 22 O (1) OWNER Name I Jr'// �� �� J / !- fZ hrs' ✓J ��(,/ 1l4,� 114 Sec !� T ZZr NR �`�' WM U (2) LOCATION OF WELL County r f� (2a) STREET ADDRESS OF WELL (or nearest address)p� Qr�- rp�V /� TAX PARCEL NO C10/ /O' o Z. Q 11U iViJ I E 1 ciJ (3) PROPOSED USE I a.mestrc 0 Industrial ❑ Municipal (10)(1WELL LOG be DECby OMMISSIONING IN a oRmC EDURE nal and DESCRIPTION Sstructure,IPOnd 0 Irrigation 0 Teat Well I E cal Oftj4r -.COLO ) V! ❑ DeWater r i c r d1 Er • . Ts kind and nature of the material in each stratum penetrated,with at least ^�� one entry for each change of information Indicate all water encountered y (4) TYPE OF WORK Owner's number of well(if morethan one) MATERIAL FROM TO C thew Well O 1 O 0 Deepened 0 Dug 0 Bored c14 3/U.r /tr /� O Reconditioned 0 C bio 0 Driven C 0 Decommission > tary 0 Jetted e.t a o inches s� r C 4y y�y C J ..r.. (5) DIMENSIONS Diameter of well l 2 CZ Drilled SLS feet Depth of completed well L II �p }� 8- E �/ec1 J ��,/ Q�/ g (6) CONSTRUCTION DETAILS 0 ft to l�� ft o Cee Installed [ 7 L o Ca ed Diam from Sr�Jt C�4i �/lYLy c trier installed Dam from 12• k to /2.�° it 1/ J Diam from ft to ft s 0 ThreadedFi.W. Cr ezI c,7`416 7 Z 7 rCyt s.. Perforatlona ❑Yes o F/ink S4A/Ze tdi ` e' Type of perforator used SIZE of perforations in by in f()5 0 Perforations from ft to ft Ck,y 11 7I c - T. e iOS 1 o8" co Screens es O No ❑K-Pac Location /Q q Manufacturer's Name GA-l/€Ser) a/t�th? C(��S �� Z.. a) Type -5/Ta,4/dSS Model No J Diam £ Slot Size /S from /22. ft to //7 ft >, Dram f Slot Size /0 from /17 ft to 11 Z ft RGravel/Fitter packed ❑Yes ( 0 Size of graveVsand lc'/- T` P s/1:, L"w r✓ Itto ft S.. Material placed from ..4 (III t I 1 \ Surface seal ea ❑No To what depth? /8' ft . 4, Matenal used in seal ./34,24702/-fr 1 O Did any strata contain unusable water? ❑Yes Ica , r. : G i, n c Depth of strata i�.- - , Type of water? tt L,. , w` ,ZIT C w 8 4115 Z Method of sealing strata off fy (7) PUMP Manufacturero -P 's Name - e H P i it iillt`,,L TS >1 (8) WATER LEVELS, J ei irl*l a elevation above mean sea level y /p- r5^(JQ Completed /D`p - C..20Static level t a fj ft below top of well Date Dr' A ... Work Started P o Artesian pressure lbs per square inch Date Artesian water is controlled dy V (Cap,valve.etc) WELL CONSTRUCT/ON CERTIFICATION w I constructed and/or accept responsibility for construction of this well,and its $4.- (9) WELL TESTS Drawdown is amount level is lowered below static level compliance with all Washington well construction standards Materials used Q Was a pump test made O Yes lJ'IVo fi yes,by whom? and the information reported above are true to my best knowledge and belief .W+ Yield gal/min with ft drawdown after hrs C Yield gal/min with ft drawdown after- hrs Type or Print NameGrt4/L.(..J///4mf License No„[, E Yield oat/min with ft drawdown after hrs (Licensed DntlerlEngineer) Recovery data(time taken as zero when pump turned off)(water level measured from Trainee blame License No tL wap top to water level) `/ r Dntlin /17 i / •.- • ` Q. Time Water Level Time Water Level lune Water Level 9�mP { r i /rt, ��, (Signed).�4 W v s.I License No 1L (Licensed Dnller/Engrneer) C Address 7y/ et.) -SC?4i'rs �"�'fict/] -C Date of testdrawdownContractors ' ' �-- Bailer test �L_a —8�����fi after hrs Registration No G/�l I.�/ 0.5/0T Date/V"�O CO Airiest gal/min with ft drawdown after hrs Artesian flow q p m Date �� (USE ADDITIONAL SHEETS IF NECESSARY) Temperature of water Was a chemical analysis made 0 Yes I�IVo Ecology is an Equal Opportunity and Affirmative Action employer For special accommodation needs contact the Water Resources Program at(360)407- ECY 050-1 20(11/98) Q `�T Z 6600 The TDD number is(360)407-6006 TRUE BUILT HOME INC Page 1 of 2 1111 • • - Home Espanol Contact Search L&I A-Z Index Help M}L&I Safety&Health Claims&Insurance Workplace Rights Trades&Licensing Washington State Department of Labor & Industries TRUE BUILT HOME INC 2522 N PROCTOR PMB 32 Owner or tradesperson TACOMA,WA 98406 Principals 253-272-5300 MANN,LEWIS DEWITT,PRESIDENT PIERCE County Doing business as TRUE BUILT HOME INC WA UBI No. Business type 602 792 223 Corporation License Verify the contractor's active registration/license/certification(depending on trade)and any past violations. Construction Contractor Active. Meets current requirements. License specialties GENERAL 4iajv, 11.License no. TRUEBBH925CD Effective—expiration 02/04/2008—02/04/2018 SCr Je/*O `f $ 2d'S Bond RLI INS CO $12,000.00 "SON Bond account no. �/V1, LSM0042128 Received by L&I Effective date 02/04/2008 02/01/2008 Expiration date Until Canceled Insurance ................. INTERNATIONAL INSURANCE COMPAN $1,000,000.00 Policy no. IG011000391-04 Received by L&I Effective date 01/27/2016 02/01/2016 Expiration date 02/01/2017 Insurance history Savings No savings accounts during the previous 6 year period. Lawsuits against the bond or savings Cause no. s smised 13-2-00235-6 Dismissed _.._ _s d Complaint filed by Complaint against bond(s)or savings BETTER,PAUL&CYNTHIA LSM0042128 Complaint date Complaint amount Help us improve 07/23/2013 $0.00 https://secure.lni.wa.gov/verify/Detail.aspx?UBI=602792223&LIC=TRUEBBH925CD&SAW= 9/8/2016 TRUE BUILT HOME INC Page 2 of 2 • • Cause no. 12-2-00162-3 Dismissed ................. Complaint filed by Complaint against bond(s)or savings KNS BUILDERS LLC LSM0042128 Complaint date Complaint amount 01/26/2012 $28,000.00 Cause no. 11-2-01929-0 Dismissed ................ Complaint filed by Complaint against bond(s)or savings KENNITH&NICHOEL PARSONS LSM0042128 Complaint date Complaint amount 09/07/2011 $0.00 L&I Tax debts No L&I tax debts are recorded for this contractor license during the previous 6 year period,but some debts may be recorded by other agencies. License Violations No license violations during the previous 6 year period. Workers' comp Do you know if the business has employees?If so,verify the business is up-to-date on workers'comp premiums. L&I Account ID Account is current. 076,721-01 Doing business as TRUE BUILT HOME INC Estimated workers reported Quarter 2 of Year 2016"11 to 20 Workers" L&I account representative T5/THAO NGUYEN(360)902-4276-Email:NGUV235@Ini.wa.gov Workplace safety and health Check for any past safety and health violations found on jobsites this business was responsible for. ©Washington State Dept.of Labor&Industries.Use of this site is subject to the laws of the state of Washington. Help us improve https://secure.lni.wa.gov/verify/Detail.aspx?UBI=602792223&LIC=TRUEBBH925CD&SAW= 9/8/2016 Septic Inspection Page 1 of 2 • 410 A27.2tirr> �e:� 2 _;_7t. Jefferson County Public Health `f Port Townsend, Washington Step 6 New Homeowner Operation & Maintenance System System Inspection Report This inspection was performed on system SOM08-00030 on parcel 901104033 by Michael Henson on 08/08/2016. This inspection report is not valid unless the required fee is paid t PH. Quit Print Page Date of Inspection: 08/081201 Septic Tank Questions: Sep , • Is the house occupied regularly? (more than 4 months a year) Yej►' '8 • Do the risers appear to be watertight with no visible leaks? P� , X018 (Check for leaks using the hose test shown in the video.) Yes v O • Are the risers free of cracks or visible damage? Yes v O(j • Are the riser lids securely fastened? Yes 'laCO • Is the liquid level in your tank: At the base of the outlet pipe v • Is the tank free of strong overpowering odor? Yes v • Does the scum layer look like living, healthy soil? Yes v • Can you clearly see baffles above the scum layer? Yes v • Is the scum layer well below lid opening? Yes v • Are baffles free of clogs and leaks around the seals to the tank If the baffle is concrete, is it intact and not corroded? Yes v • Is the inlet baffle intact and in good condition, not corroded? Yes v • Is the outlet baffle intact and in good condition, not corroded? Yes v • Can you see roots growing into the tank around the baffles and pipes coming into and out of the tank? No v • What is the scum depth in the inlet side of the tank? 2 inches v • What is the sludge depth in the inlet side of the tank? 12 Taches v • What is the scum depth in the outlet side of the tank? less than 1 inch v • What is the sludge depth in the outlet side of the tank? less than 1 inch v • What is the total scum and sludge depth on the inlet side of the tank? 14 inches V • What is the total scum and sludge depth in the outlet side of the tank? lass than 1 inch V • Does the tank need pumping? Yes v • Did you clean the outlet baffle filter? Yes • Is roof run-off and drainage diverted away from all tanks? Yes v Pump Tank Questions: • Is the riser watertight and free of cracks and damage? Yes • Are the riser lids securely fastened? Yes v • Is the pump tank free of solids? Yes • Is the pump tank free from corrosion or damage to any of the pipes? Yes v • Is the electrical junction box intact and free from corrosion or damage to the wires? Yes • Are the floats attached to the float tree and not hung up on anything? Not Applicable v • If there is a basket screen present, is it intact and not collapsed or clogged with solids? Not Applicable v* • Does the alarm sound when the alarm float is lifted? Net Applicable v • Is the control panel free of any leaks, corrosion, or loose wires? Yes v http://jeffersoncountypublichealth.org/septic/insp view.php?UserID=SOM08-00030&insp_date=2016-08... 8/16/2016 Septic Inspection Page 2 of 2, • If you have a traucer pump (no floats) did you replace battery in the control panel? Yes Pressure Drainfield Questions: • Are there any strong odors? No • Are there any mushy or swampy areas or surfacing effluent present over the drainfield? No • If inspection ports are present, is there standing water in the ports that is still present 2 hours later? No V • Is the drainfield area free of parking, driving, decks, other structures? Yes u • Is roof run-off and drainage diverted away from the drainfield? Yes V Corrections: None Needed Comments: I will arrange for pumping out tank before September 1, 2016 Please Contact Environmental Health DIY Program Staff if you feel you have made an error in your report or need to change anything. Include your Geo ID (parcel number), User ID and the Inspection Date in any communication about this inspection. Click below to go to Jefferson County Environmental Health Services. Jefferson County Environmental Health Services acs http://j effersoncountypublichealth.org/septic/insp_view.php?UserID=SOM08-00030&insp_date=2016-08... 8/16/2016 ONow DEPARTMENT OF COMMUNITY DEVELOPMENT 'cc621 Sheridan Street,Port Townsend,WA 98368 Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.jeffexson.wa.us/communitvdevelopment !� E-mail:dcd@co.jefferson.wa.us -'15C.; IN��� PERMIT FEES WORKSHEET Name michael ^ Mary Parcel# 901104033 Estimated Cost of Project $12,500.00 Permit# NSF Building Base Fees Building Base $1,202.00 Plan Check Review $781.30 Land Use Review $255.00 Septic Review $129.00 Potable Water $172.00 -$1f,f7A:7ht 1 $21.00 Technology/Scanc I � . State Fee SEP 1 $4.50 AFF ?016 Fids®A, Other Fees TYDO Shoreline Exemption Zoning Zoning New Address Public Works Total Fees $2,564.80 Office Use Only Receipt Number: .0O Cash/Check/CC: yS Date: 9/9/c . . Oa Front Parcel Review6i6-0.04(0( Parcel 901104033 • Printed: September 8, 2016 MICHEAL S HENSON Site Address(es): MARY BETH HENSON 2086 ANDERSON LAKE RD CHIMACUM, WA 98325 PO BOX 398 Chimacum,WA 98325 Parcel Number: 901104033 S-T-R: 10-29N-1W Total Acreage 6 Legal Description CHIMACUM HEIGHTS SHORT PLAT LOT 3 SUBJ TO Land Use: 9800 EASE/OPEN SPACE TRACT A Flood District: Fire District: 1 Planning Area: Flood Map(FIRM)Panel No: School District 49 Zoning: ' COMP PLAN DESIGNATION: COMMUNITY PLAN: UGA: UGA Trans _3\J Plot plan states "property line" Assessor's Map (Property lines on submitted plot plan must atc he property lines as identified on the Assessor's 1/4 map) C>:], Legal Access to Property QE NO P(o i i a Parcel Tags or Scanned Documents 0 2. _ Ac i.c • . ESA's: Special RepoAk,earby g) NO \ '` (p Le fez - C -R K ' Designated Ag YES / 0 Shoreline Designation: YES [ Shoreline Slo. Stability: YES Stream Typ:tre NO r-- st' A) Sr.&' i Yi FWHCA: AZ. NO / n 't IN •_ iA11 r4s Wetlands: YES Rare Plants:YES dif�J Seismic: YES t, Landslide:0 NO 5 'I co 4-- r (,7 a CASs r:� d o P Flood: YES 6 L 0Erosion: YES ( � Aquifer Recharge Area: NO ,��,�11A --)- S SIPZ: s •e At Risk High Risk Coastal CMZ: e High Risk Mo rate RiskDisconnected CMZ Stormwater site plan submitted: e No 5 ---Vb * Forest Lands: YES (Noj Adjoining Forest Lan : Commercial/ Rural/ Inholding [�] Mineral Lands: YES IS Agricultural Lands: YES Archaeology: YES —60 [>-] No Shooting Zone: YES 461 Stormwater: New I ervious Surface ,\ Land Disturbing Activity .5 c _ ESA's Stormwater Req's:Min R q#2 Min eq#1 thru#5 Min Req#1 thru#10 _meering <], Notice Provisions/Disclosure:Airport YES 09 MRL YES rro Forest Lands YES Landscaping Required: Yes ] Parking Spaces Required NO © Other 1 Building Height: ( 5' UBC Standard Impervious Surface cove e percentage: -P-2.- ' f Resource Lands&Public: Rural Residential'25% Rural In Tial: Per UDC Sec 6.7 Rural Commercial: 60% Area of Building Coverage: 60%in Rural Industrial Lands only N. Total Building (s) Size: ,,, ARVC:20,000 SF CC: 5,000 SF NC: 7,500 SF GC: 10,000 SF All others:subject to septic&water constraints/None specified j Setbacks: Front: ; ` Left Side: L�' Right Side: (' Rear: Shoreline Setback: Vot4:13 LSHA Setback: Cr + 5 ' loUfddzn/� • Road Classification: `OC• \ (kc s,s5 (2 c r yt le—r3 Road Approach: EXISTING T RE. I RAP SEPA Required: YES i4114 v\bike ` /j —f[ ``g) 0 C .-)09) (Rt j>< Flood Certificate: ] Existing Case(s) &Condition(s): 1601/k/ kViolations: Yes No ] Recorded Date of Subdivision: r 01//1-/s0f AFN 11-/ 101-1.1-- Over 5yrs=UDC Plat Conditions: ] 4� 1 .. , 4i v( ,E,-:6 `]` Plat Conditions on plat or Old Ordinance f] Lots/Require Declaration of Restrictive Covenant YES NO, submitted: YES NO K] UGA No Protest Agreement YES-. NO, submitted: YES NO Site Visit conducted YES [ Require Final Zoning Approval YES N-' ADMIN: Setbacks entered in Permit Plan case /'N YES New Parcel Tags entered in Permit Plan Nom.../ YES Special Reports Scanned N/A YES Title Notes *171/1(k0(1, _�%.1 r 1 Updated Parcel tags found for parcel 901104033 � r 1 D c 1.) WSRC Coaching - 2013-02-13 landslide, run off,-5G VPE' 08/27/2013 Other Parcel tags found for parcel 901104033 2.) WSRC Coaching - LID 2012-07-16, SG 08/27/2013 Parcel tags found for parcel 901104033 3.) WSRC Coaching - 2012-07-16, SG 08/27/2013 CAO Cases Associated with APN 901104033 Review Cases Name Type Status Planner BLD16-00401 HENSON P Emma Bolin Application Received: 9/8/2016 Permit Issued/Case closed: Case Finaled: NSF SEP08-00030 M LA08-00088 PRJ11-00194 MLA08-00088 HENSON F Application Received: 9/5/2011 Permit Issued/Case closed: Case Finaled: SEP08-00030 MLA08-00088 HENSON F Michelle Farfan Application Received: 2/20/2008 Permit Issued/Case closed: 7/16/2008 Case Finaled: 7/14/2011 M LA12-00252 BLD12-00367 MLA12-00252 HENSON I F Michelle Farfan Application Received: 11/13/2012 Permit Issued/Case closed: 12/12/2012 Case Finaled: 10/4/2013 (Revised) NEW DETACHED GARAGE -w/shop and bath upstairs, (revised 7/18/2013 -MEB) PLMB, NO HEAP SUB00-00002 SNYDER F Michelle Farfan Application Received: 5/26/2000 Permit Issued/Case closed: 8/21/2000 Case Finaled: 2/14/2001 To subdivide 15 acres into three 5 acre parcels. RAP09-00038 HENSON C Application Received: 6/3/2009 Permit Issued/Case closed: Case Finaled: 6/8/2009 No Rd Approach Required -Already Existing. Assigned Address only. RAP &911 -ANDERSON LAKE RD \\tidemark\data\forms\R_Parcel_CRMLA.rpt 9/8/2016 Page 2 of 3 SOM08-00030 HENSON RCD Application Received: 9/5/2011 Per tit Issued/Case closed: 8/8/2016 C inaled: USR00-00048 SNYDER F Application Received: 7/6/2000 Permit Issued/Case closed: 4/22/2013 Case Finaled: 4/22/2013 Two wells have been drilled for this subdivisio and for this application.. single connection on 901104033 and 2 party well on 901104031 (serves 901104031 &901104032) \\tidemark\data\forms\R_Parcel_CRMLA.rpt 9/8/2016 Page 3 of 3 D 2c BLD16-00401 BUILDING PERMIT APPLICA ON Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD16-00401 Received Date: 9/8/2016 SITE ADDRESS: 2086 ANDERSON LAKE RD CHIMACUM, 98325 OWNER: MICHEAL S HENSON PHONE: 425-638-9816 MARY BETH HENSON PO BOX 398 Chimacum WA 98325 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901104033 Section: 10 Township: 29 N Range: 1V1 CONTRACTOR: TRUE BUILT HOME INC PHONE: 253-777-1714 2522 N PROCTOR PMB 32 TACOMA WA 98406 Contractor's License TRUEBBH925CD Expires 2/4/2017 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NSF SEP08-00030 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 884 VALUATION 125,000.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2012 OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: SHORELINE: GA CONST TYPE: DECKLE 112 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 1 PWELL BEDROOMS: BATHROOMS: Type Amount Paid By: Date: Receipt Exist: 1 Exist: 1 Permit $1,202.00 SRE 09/08/16 165680 Prop: 1 Prop: 1 Total: 2 Total: 2 Plan Check $781.30 SRE 09/08/16 165680 Consistency Review $255.00 SRE 09/08/16 165680 Approved/Date Scanning Fee $21.00 SRE 09/08/16 165680 State Building Code $4.50 SRE 09/08/16 165680 EH SEP/RES Rev $129.00 SRE 09/08/16 165680 DCD Water Review $43.00 SRE 09/08/16 165680 Potable Water Application $129.00 SRE 09/08/16 165680 Total: $2,564.80 1\tirlomnr4\riotn\fnrmc\F RI fl Ann Rlrt rnt aiszoniR • • JEFFERSON COUNTY 6 DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street I Port Townsend,WA 98368 I Web:www.co.Jefferson.wa.us/communitydevelopment 4. 77 Tel: 360.379.4450 I Fax:360.379.4451 Email:dcd(c�co.jefferson.wa.us Building Permits&Inspections Development Consistency Review Long Range Planning! Watershed Stewardship Resource Center REQUEST FOR WAIVER FROM SPECIAL REPORTS l owner of parcel Property Owner's Name Parcel number located at Property Address hereby request a waiver from the requirement for a Type of Special Report under iCC 18.22.370, in association with critical area review and protection standards under JCC I for permit application for the following reasons: Code Section permit case number 18.22.370 Waivers. The administrator may waive the requirement for a special report when an applicant demonstrates all of the following: (1)The proposal involved will not affect the critical area in a manner contrary to the goals, purposes and objectives of this code, because: (2)The minimum protection standards required by this chapter are satisfied, by: Signed Property Owner Date Staff Comments: SON co <,"' „.: '''...:.. . 6- • DEPARTMENT OF COMMOTITY DEVELOPMENT W ', � 621 Sheridan Street,Port Townsend,WA 98368 Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.jefferson.wa.usicommunitydevelopment, dcdna co.jefferson.wa.us , f ..........") >t ��S IN�.~i0 I. , .,+ 1 PERMIT APPLICATION 1. Steps in the Permit Process: 0-Review application checklist to ensure all information is completed prior to submittinp licati6 ' -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. w -This is not a standalone application; it must be accompanied by a project specific supplement' plication. -Fees will be collected at intake. Additional fees may apply after review and payment is required be permit is issued. For Department Use Only Building Permit# Related Application#s: " MLA# . J Site Information Assessor Tax Parcel Number: cio 1 /o 11 0 33 Site Address and/or Directions to Property: _a' ""8- ( 2 a\A 1 EP -iv A CAA M , t!.i 4 c?F S Access(name of street(s)) from which access will be gained: 74 .& L E Sc/ts L*kF Pc/. Present use of property: s e , ) ACe7 E rseJ6) g S Descriptionof Work(include proposed uses): /J$'-j---p Q(_—r- I s3k j /3.4-7-# / 5-oAy jio Wastewater-Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: x Septic Septic Permit#: moi- c -- _' i.•i 3e Community Septic Name of System: N / - != , ^, -0 Case#: Are other residences connected to the septic system? /'() Additions or repairs to sewage system: Al/4 Is it a complete or partial system installation: Complete < Partial Has a reserve drainfield been designated? Yes } No Attach last report to Date of Last Operations& Maintenance check: 090 zo/6application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: 1,,,,,1:.aholicuion Paoc 1 of 2 F The authorized agent/representative is tprimary contact for all project-related questi and correspondence. The County will mail /e-mail requests and information abou application to the authorized agent/repressive and will copy(cc)the owner noted below. The authorized agent/represents e is responsible for communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e., County email is not blocked or sent to "junk mail ) afi t v .- " s ; 4 (` t `, " ; AplantfProetty Ownernfomat1o6 . _ az ,2 - ' Property Owner: AleSC3�1 l Name: �� ( e _11,1j. �e M y 12p iv � i Address: % ,)( f8 � 1 tea co i , wit 9&'3 "eS Phone#: '/Z$ 6 .39 9's3►b) E-mail Address: tk.ttf k 1> 'A-1©e MSA/ w. C°0 .,t Please contact A uthorized Agent/Representative with project info. (select only one). Property Owner Signature:, 4 40. _I 04 s Date: g/l7/2,:n/ 4 Note: For projects with multiple owners,attach a separate sheet th each owner(s)information and signatures. fi Aw . ,., +:&s. n, 3 i , ,zy - .z: , i e s r g 8'c a .`-1:rdt -�' •`d' bec., Applicant ;Yluthor�zec�AgenV131p* p,n atfiye,' ffothe thar,nwner) ,A. ' �. . .... ,.._.. : Name: Address: Phone#: E-mail Address: O fessronal" t- Agthis an luthortzeg,Age irAepresentaVe forRhistGrai.7 FI`lO S Engineer Architect Surveyor Contractor Consultant Name: LA iAilotki)e. License# crBZSC cC Address: —Z...,.. —az_. / b ry5i` f f, €- --tCq ui Phone#: Z-5-3 Z Z. 5-300 E-mail'Xddress: 7 l 4;1 Slie is this an Authorized.Agent/Represer)tatiye for this pro�eet NO Professional �� ;,..y , .__.. � v��'�.'.�`5 Ji:.* . Engineer Architect Surveyor Contractor ,-------- Consultant Name: c 4.k/l 5_ ,t - 6()0e_ License# L Address: (.-,kQ z Lai '1- 636-i1 e Phone#: E-mail Address: g l ,•. ata e resentative forthfs rr� ect� =ANO xS ?�rofessaonal �-_��'_�; 1s�tfi�s an�u��orJzec3,A�ent/�,�� __. . .__.�,. �_ ��: .,.��_.J_.�F.,._�.�..:� �:.N.. ._.��_ �,�, �-�:� � '....> ,. �.__ Engineer ArchitectSurveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: 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 or her 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I 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. Applicant may request notice f the C unty's intent to enter upon the property for visits related to this application and subsequent permit issuance. Signature: ___0: 5-----( Print Name: 10�)1Q e/ A) 4)Date: e/2_ /c- 1 - , ttior. .2 oi 2 4sON a DEPARTI NT OF COMMUNITY DEVE•PM NT. . „<f,, 621 Sheridan Street,Port Townsend,WA 98368 C f%,� i 4t, ,.�� Tel:360.379.4450 I Fax:360.379.4451 '`l,'J9 'x+0,7 c '-' ',' '-< Web:www.co.Jefferson.wa.us/communitydevelopment � ' E-mail:dcdeco.jefferson.wa.us / i j• � ' , . ,r SFA I. (skl NG'O SUPPLEMENTAL APPLICATION ��'�. %g RESIDENTIAL OR COMMERCIAL BLDG PERMVV <a/ For Deparf.i ent'Jse=On1 e x Y r� a r�3'? ..� k, y 'f, *A-0107`$ i'-'sl ' i .<, a rxi 4., " -a^'t �a �zo� -�'' ri�� }'�4� t �tt ly 5� ms's t t � tr '��` t^4. Related Application#s .. ,� n - V * r Slte nfor'rnatlolt ,t, tr °', ... ° ',. te e s y rM p;, q ge r x`t = t : , Owner Name: A c>; ., i .Ai E • Assessor Tax Parcel#: `lot 1 d7 0 33 r F tea --r .:y. Type of Budding' New Replacement _ Relocated Addition— _ Repair Demolition * *A separate permit is required Select One: Single Family Residence _ Modular_ — Other list Proppsecl'Buildirtg/Project ,,:,-::,'i:..:.,.. , Number of floors I #new bedrooms / existing 19 total bed #new bathrooms / existing / total bath a Heat=Source t' ; _ 3 f x Select all that apply: ,. . � �� ._._, . ... . ,�.x�. ..�-�� �, -. •� .�.�. Electric 2`. Heating Oil Wood Propane Enter the square footage(sq/ft)that applies in each field: Structure r,x ,,� ,; a _ r _,_. - ',:Existing tSq/Ft Proposed Sq/Ft ICC Valuation(Office use) �? ,,,, � �. Residential/Commercial Main Floor � �� ,;_4..., k�. Y Residential/Commercial Second Floor 00 ; gg Additional Floors -heated/unheated V ar k ` ' *`k t Basement-unfinished . .�- ;I., Basement-finished space or habitable '''''''" a Detached Garage-heated/unheated -- e ? V.015-%.!71.1,415,1,14''7 �� w� , ' Attached Garage-heated/unheatedi�r Garage 2nd fl-unfinished storage Garage 2nd fl-finished space or habitable 3` , ,,,s Carport-2 walls or less fi wry Deck- uncovered ki m Covered porch 1/2 4 iT cgs Other(shed, barn, pole bldg,etc.) t = ',: evil s , Estimated Cost of Project (Required): $ ,575-0®0 l'25-)000 $ Supplemental SFR List existing buildings on property (house,garage,accessory dwelling unit,she , barn mobile home, other): All lr dstin Buildings on Property r • . -��,: °i ti P tiM. ,2 ^�,°,'+€;"" Fs35,rs� `��'w ''�`�, S�ru'sM� rs ,..� �" �" � �s i.:�,,,`�7,s�Gam•' }s-'��. �". � ��...'. P p B(lll O"Eilfl T1':' ntW;•1 z ` 4�.'r -`.3r,.�-:� ttaag �. ? m The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that hey will be assuming the responsibility of the General Contracto for the proposed project. Signature: M Print Name:M i C-14ct e) emlo ate: �7/tlam( i4, l 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 or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respec to this;application packet may result in making any issued permit null and void. /7 20/C Signaturef �j � - - � Print Name:///���,,,,/(0),/ad geluscy6 Date: Building Permit Fees Building Base Plan Check Review Land Use Review $255.00 Septic Review $129.00 Potable Water $172.00 Technology/Scan $21.00 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Total Fees Receipt# Date: Cash/Check/CC: Supplemental SFR BLD16-00401 Request for Wer on DCD Letterhead.pdf Word Online 46 Save to OneDrive ifr.4 Print .P Find Pv Do A aillgifo n15"i_e_4()(6 WetIMIrer (Vdp/C/0 JE.14ERSO4COUNrY • y:\ DEPARTMENT OF COMMUNITY DEVELOPMENT n I V4',3 ei; 31, -9crlr;.-.,7€ 1.1..Fe'Vii,S= Svts .7.` REQUEST FOR WAIVER FROM SPECIAL REPORTS We,Michal S.and Mar?Beth Hensen,owners of parcel 901-104-033 located at 208 Anderson Lake Rd, Chirnacum,WA 98325 hereby request a waiver from the requirement for a geotechnical report under ICC 13.22.370,in association with critical area review and protection standards under.ICC 18,22.170 for permit application 8LD15-00401 for the following reasons: 18.22.370 Waivers. The administrator may waive the requirement for a special report when an applicant demonstrates all of the followIng: (1}The proposal involved will not affect the critical area in a manner contrary to the goals,purposes and objectives of this code,because: frer—A 744 -7EA1 (2)The minimum protection standards required by this chapter are satisfied, by u /0) 1 c rut40ff6-Doki p royal -lure cx uticLy b -ice s— ZeD/I)e.. ot bud /-90 of 6ct e - Ve5g ,,i47 („L Signed 0 _9(2_0_5—Z/1 teZCV 20/8 pr...,pot,Owner 1)4 g Staff Cornmes: sotEilvE OCT - 3 2016 JEFFERSON COUNTY DEPT.OF COMMUNITY DEVELOPMENT • + Emma Bolin Subject: Planning Team Huddle Location: DCD Conference Room Start: Mon 10/10/2016 8:30 AM End: Mon 10/10/2016 9:00 AM Recurrence: Weekly Recurrence Pattern: every Monday, Tuesday,Wednesday, and Thursday from 8:30 AM to 9:00 AM Meeting Status: Meeting organizer Organizer: Jodi Adams Required Attendees: Anna Bausher; David W.Johnson; Donna Frostholm; Emma Bolin; Haylie Clement;Joel Peterson; Patrick Hopper; Patty Charnas; Michelle Farfan All Planning Team members are encouraged to attend the full meeting in order to contribute and learn, however planners may attend or leave based on their work demands,vacations,trainings and items to discuss on the agenda. The meeting will begin with any general Planning Team issues, Case/CAM distribution and then agenda items in order. Any items not discussed at a meeting due to time limitations will be given priority for the next day's meeting. We will start and end on time. Meetings will be 8:30-9:00 am Monday—Thursday and 9:00-10:00 am on Fridays. 1. General Planning Team Issues 2. Distribute new cases& CAM requests 3. Geotech Waiver= remove buffer and building setback?- EDB 4. 5. 6. 7. 8. 9. 10. 1