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HomeMy WebLinkAboutBLD2015-00258 - 01 PERMIT APPLICATION BLD15-00258 131PILDING PERMIT APPLICATI r Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00258 Received Date: 7/28/2015 SITE ADDRESS: 2755 TARBOO LAKE RD QUILCENE, 98376 OWNER: T- MOBLIE PHONE: 206-336-2881 MATT ENGLESBY, PTS 568 FIRST AVE S., SUITE 650 SEATTLE WA 98104 SUBDIVISION: Block: Lot: PARCEL NUMBER: 801181001 Section: 18 Township: 28 N Range: 1V1 CONTRACTOR: TBD PHONE: 253-584-6606 REPRESENTATIVE: CROWN CASTLE ON BEHALF OF T-MOBILE PHONE: 503-709-0820 1505 WESTLAKE AVE #800 SEATTLE WA 98109 PROJECT DESCRIPTIO) CELL TOWER- PROCESSING AND REPLACE 3 ANTENNAS, REPLACE 1 MICROWAVE- INSTALL 3 REMOTE RADIO UNITS AND 1 BASEBAND MODULE TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: TYPE OF IMP REP MAIN: INDUSTRIAL: VALUATION 45,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: CONST TYPE: OTHER: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: NUMBER OF EMPLOYEES: WATER SYSTEM: BATHROOMS: Exist: Prop: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $532.00 SRE 07/24/15 156358 Plan Check $345.80 SRE 07/24/15 156358 APPROVED State Building Code $4.50 SRE 07/24/15 156358 Total: $882.30 SEP 0 2 2015 Jefferson County DCD \\firlomor4\rloto\fnrmc\F RI fl Ann Rid rnf 7/9R/91)1F • • CROWN Crown Castle Cr CASTLE 1505 Westlake Avenue North,Suite 800 Seattle, WA 98109 11-=)) 101 July �1 A July 21,2015 Jefferson County { J U L 2 3 2015 J, Attn: Dept.of Community Development 621 Sheridan Street JEFFERSON COUNTY i)FPT,OF CO",MMi'NITY OFVFLOPMrNT Port Townsend,WA 98368 —=- RE: Eligible Facilities Request to modify equipment on a communications Tower Crown Site 826843/Crown Site Name:PT Lake Tarboo T-Mobile Site ID SEo61o6A Crown Castle on behalf of T-Mobile West LLC is submitting the attached Eligible Facilities Request application to add, remove,modify,or replace Transmission Equipment on a telecommunications Tower located at 2749 Tarboo Lake Road,Quilcene,in County of Jefferson,WA. Section 6409 of the Middle Class Tax Relief and Job Creation Act of 2012,commonly known as the"Spectrum Act" (Pub.Law No.112-96,126 Stat 156),mandates that state and local governments"may not deny,and shall approve,any eligible facilities request for a modification of an existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base station." Under federal law,an Eligible Facilities Request is deemed granted sixty(60)days after a complete application is filed with a local jurisdiction. T-Mobile proposes to modify an existing unmanned Wireless Communication Facility as follows: • Replace(3)antennas,replace(1)MW, • Install(3)remote radios units,install(1)baseband module on the ground Itemized list of submittal documents: • Cover letter • Certification of Non-Substantial Changes to Wireless Tower • Stamped and sealed final Construction Drawings(including Site Plan) • Stamped and sealed Structural Analysis report • Building Permit Application&Supplement&Copy of Memorandum of Lease T-Mobile is committed to working cooperatively with all jurisdictions around the country to secure expeditious approval of requests to modify existing personal wireless service facilities. If you should require more information regarding the Spectrum Act,please do not hesitate to contact me with your questions. Sin 7/4_ 'Tina Hwang Real Estate Project Manager I Office:206-336-2881 I Email:Tina.Hwang@CrownCastle.com The Foundation for a Wireless World. CrownCastle.com • . ELIGIBLE FACILITIES REQUEST CERTIFICATION FOR e - kit! ��-` . f� 1 CHANGES `) TO A WIRELESS TOWER NOT LOCATED WITHIN A PUBLIC'1GHT OF WAY 2015 1) Address of the Wireless Tower: _2805 Larson Lake Rd., Port Ludlow (826842) _ Li 2) The height(measured in feet above ground level) of the existing Tower as orii -ye°1 r��*�� approved, including any modifications approved prior to February 22, 2012 fig- ' 3) What is the height(measured in feet above ground level) at which the modifications to the Transmission Equipment will occur on the Tower? 197' 4. What will be the height(measured in feet above ground level) of the existing Tower after the modifications to the Transmission Equipment are installed? 195' 5) Effect of modifications of Transmission Equipment on Tower height: (A)Will the modifications in Transmission Equipment (addition, removal or replacement of Transmission Equipment)result in increasing the height above ground level of the existing Tower? El Yes ® No (B) Will the modifications in Transmission Equipment result in increasing the height above ground level of the existing Tower by more than: (i) 10%of the height of the existing Tower, as originally approved, including any modifications approved prior to February 22, 2012; or(ii) twenty feet above the height of the existing Tower, as originally approved, including any modifications approved prior to February 22, 2012, whichever height increase is greater? n Yes a No 6) Will the modifications in Transmission Equipment (measured at the height above ground level where the Transmission Equipment will be attached to the tower) result in any Transmission Equipment protruding horizontally from the edge of tower by more than twenty(20) feet or by more than the existing width of the tower at that height, whichever of these dimensions is greater? ❑ Yes VI No 7) Will the proposed changes in Transmission Equipment involve excavation or placement of new equipment outside the existing Tower site or outside any access or utility easements currently related to the site? n Yes ® No 8) Will the proposed modification in Transmission Equipment involve installation of more than the standard number of new equipment cabinets for the technology involved, but not to exceed four? ❑ Yes M No Non-Substantial Change Certificate for Towers Not Within A Public Right of Way National Development 2015.3 9) Will the proposed modification in Transmission Equipment defeat the existing concealment elements of the Tower? ❑ Yes Ef No (10) Prior Conditions of Approval (A)Will the proposed modification in Transmission Equipment comply with conditions of approval imposed on the Tower prior to February 22, 2012? ® Yes n No (B)If the answer to 10(A) is "No," is the non-compliance due solely to any of the conditions addressed in questions 5-9 above? n Yes n No If the answer to either question 5A or 5B is "No", and the answers to questions 6-9 are "No", and the answer to either 10A or B is "Yes" then the proposed modifications do not substantially change the physical dimensions of the existing Tower. Please provide a brief explanation, if necessary, to clarify any answer. Explanatory Comments (If Needed): Question No. Comment: This certification is dated this 21 day of July, 2015. Signature Tina Hwang, Real Estate Project Manager Name & Title Non-Substantial Change Certificate for Towers Not Within A Public Right of Way National Development 2015.3 • . DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 Tel:360.379.4450 Fax:360.379.4451 _ Web:www.co.jefferson.wa.us/communitydevelopment'4 I _, E-mail:dcd(a co.jefferson.wa.us 1 h iNG ° PERMIT APPLICATION J U l_ 2 3 2015 Steps in the Permit Process: JEFFERSON COUNTY -Review application checklist to ensure all information is completed prior to submitting'2ppfE5fioi±JNITY DEVELOPMENT -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. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -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# Site Information Assessor Tax Parcel Number: 801181001 Site Address and/or Directions to Property:2749 Tarboo Lake Rd, Quilcene, WA 98376 Access(name of street(s)) from which access will be gained: Tarboo Lake Road to gravel access road Present use of property: Forest lands Description of Work(include proposed uses): This is an Eligible Facilities Request. T-Mobile proposes to replace (3) antennas. replace (1) Microwave, install (3) remote radio units, and (1) baseband module. Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO ✓ If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: n/a Community Septic Name of System: Case#: Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: Complete _ Partial Has a reserve drainfield been designated? Yes _ No Date of Last Operations& Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title,which may impact the property: Permit Application Page 1 of 2 • • The authorized agent/representative is the primary contact for all project-related questions and correspondence. The County will mail/ e-mail requests and information about the application to the authorized agent/representative and will co. •- o ner noted below. The authorized agent/representative is responsible for communicating the L�xxtor Q:, I ` s, Irate th the ap lication. It is the responsibility of the authorized agent/representative and owr(&�:C�: i-i1b•l'� . =. . l • my email(i.e., County email is not blocked or sent to "junk mail"). � � Applicant/Property Owner Information 4: .',r,�'','r: , f 4 ;,,,,, P-fr„ L Property Owner: ,1i\ 2 3LUi3 Name: Pope Resources Address: 19950 7th Ave NE, #200, Poulsbo, WA 98370 }�r����,,`��wN Phone#: E-mail Address: �,r�T nF�n^^ '��l'� �����` �D't�-�-� Please con t Authorized Agent/Representative with project info. (select only one). — — bio ( Qn/ Property Owner Si natures ~Tt wS le Date: /24/1.7) Note: For projects with multiple owners,attach a sep e sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(if other than owner) Name: T-Mobile West LLC (contact: Tina Hwang, Crown Castle, submitting on behalf of T-Mobile) Address: 12920 SE 38th Street, Bellevue, WA 98006 Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant ✓ Name: Tina Hwang, Crown Castle, submitting on behalf of T-Mobile Address: 1505 Westlake Ave N, #800, Seattle WA 98109 Phone#: 206-336-2881 E-mail Address: Tina Hwang@CrownCastle.com Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES Engineer Architect ✓ Surveyor Contractor Consultant Name: Roger T. Alworth Address: 5501 NE 109th Ct#A2, Vancouver, WA 98662 Phone#: 360-885-9200 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES Engineer ✓ Architect Surveyor Contractor Consultant Name: John Welton Kelly Ill Address: 1717 S. Boulder, Suite 300, Tulsa, OK 74119 Phone#: 918-587-4630 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Attach additional pages if necessary Builders Statement The signer of this statement certifies 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: Print Name: Date: Pcnnir Application I'i 2,,t 2 • . 4SON e DEPARTMENT OF COMMUNITY DEVELOPMENT OG. 621 Sheridan Street,Port Townsend,WA 98368 W Tel:360.379.4450 Fax:360.379.4451 v �� ti .0 Web:www.co.Jefferson.wa.us/communitydevelopment E-mail:dcd@co.jefferson.wa.us TI JUL 2 3 2(15 I N SUPPLEMENTAL APPLICATION Lam' RESIDENTIAL OR COMMERCIAL BLDG PERMI:,' s"�,��;Nn For Department Use Only Receipt#: Dater Related Application#s: Payment#: Site Information Owner Name: Pope Resources Assessor Tax Parcel#: 801181001 'Applicant:T-Mobile West LLC Type of Building New Replacement Relocated Addition Repair Demolition *A separate permit is required Select One: Single Family Residence Modular Other WCF list Proposed Building/Project Number of floors 195'tower #new bedrooms existing total bed # new bathrooms existing total bath Heat Source Select all that apply: Electric Heating Oil Wood Propane Enter the square footage(sq/ft)that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft Residential/Commercial Main Floor Residential/Commercial Second Floor Additional Floors- heated/unheated Basement- unfinished Basement-finished space or habitable Detached Garage- heated/unheated Attached Garage- heated/unheated Garage 2nd fl- unfinished storage Garage 2nd fl-finished space or habitable Carport-2 walls or less Deck- uncovered Covered porch Other (shed, barn, pole bldg,etc.) 1600 sq.ft.compound 1600 sq.ft.compound Estimated Cost of Project (Required): $ 45,000 Supplemental Si R t List existing building on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home,other): All Existing Buildings on Property Use 1 V _ W l By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, i-. true and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact mad: 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 perfbrm8d,,,,rr, in compliance with all applicable federal, state and county laws and regulations and I agree to provide access and T 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 rel ted to this application and subsequent permit issuance. Signature: (` Print Name: Tina Hwang,Crown Castle,obo T-Mobile Date: // -1/>()/ c Estimated Cost of Project $ 45,000 F©r De art er►t UseP: „„ " ''► �?�Y, Building Base Fees Building Base Plan Check Review Land Use Review $228.00 Septic Review $79.00 Potable Water $107.00 Technology/Scan $19.00 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt# Date: Cash/Check/CC: Supplemental SFR 2 • • 826843 T-Mobile SE06106A 2749 Tarboo Lake Rd. $ON CO, DEPARTMENT OF COMMUNITY DEVELOPM 44, yt, 621 Sheridan Street,Port Townsend,WA 98368 W Tel:360.379.4450 Fax:360.379.4451 Web:www.co.jefferson.wa.us/communitydevelopment Lam' E-mail:dcd@co.jefferson.wa.us co.jefferson.wa.us ys ,s0 � ,- ,t, 3 2015 ;� x' HIN" , . STORMWATER CALCULATION WOIIKSI.I . ouNw� MLA# PROJECT/APPLICANT NAME: T-Mobile 700-SEO61 O6A-826843 DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE(I.E.,SITE) Size of parcel 635.28 acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 27,672,796 sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative)and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing,grading,filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,and salal; herbaceous plants such as sword fern,foam flower,and fireweed. LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Does the project convert%acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank, etc. sq/ft Circle: Yes No Well, utilities, etc. sq/ft Does the project convert 2 1/2 acres or more of native vegetation to pasture? Driveway, parking, roads, etc. sq/ft Circle: Yes No Lawn, landscaping, etc. _ sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance . sq/ft Cut Fill (cu/yd) Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops,walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads, packed earthen materials,and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. stormwater calc worksheet—REV.10/20/2014 1 • ° E![--] JUL 2 3 2015 I STORMWATER CALULATIONS–IMPERVIOUS SURFPCE H JEFFERSON COUNTY NEW EXISTING DEPT Of COMMUNITY DEI7 PM11'I-F Structures(all roof area) sq/ft Structures(all roof area) sq/ft Sidewalks sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc sq/ft Driveway, parking, roads,etc sq/ft Other sq/ft Other sq/ft Total New n/a sq/ft Total Existing n/a sq/ft TOTAL NEW+TOTAL EXISTING* sq/ft *This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: Does the site have 35%or more of existing impervious surface? Circle: Yes No ✓ FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of "medium" projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Storm water Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation 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. VZ-1 (LANDOWNER OUT • r.REPRESENTATIVE SIGNATOR ) ,..J n�,' ATE) stormwater calc worksheet—REV.10/20/2014 2 • • I QO- - LsoN co DEPARTMENT OF COMMUNITY DEVELOPMENT .4,..` 64, 621 Sheridan Street Port Townsend,WA 98368 1 4, 1 CEOVIE -1 Lr4 ,--11 .--- ,.. Tel 360,379.4450 ' lax:360 3"9,445l # i \s\....... Wl) e .w\A w,c o.jeffersollNwa.us/commrn unttydevelopent 4,-; ,_.- - E-rnail:dedcolefferson wa.us ' JUL 2 3 2015 I_ i---- PERMIT FEES WORKSHEET JD I ERSC1'.1 COUNTY r-L_I(II rirI17:ITY PrVEI OPIIT"T . Estimated Cost of Project Parcel# Permit# Building Base Fees Building Base $532.00 Plan Check Review $345.80 Land Use Review $234.00 Septic Review Potable Water Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning New Address Road Approach Total Fees $1,135.80 Office Use Only Receipt Number: kSLASS' Cash/Check/CC: .] Date: Initials: RealQuest.com®-Report • • Page 1 of 1 Property Detail Report 110 E C E l For Property Located At : CoreLo 2755 TARBOO LAKE RD, QUILCENE,WA 98376 Re.It•UestJPro/"f'ssi�,naII L Owner Information �� I Owner Name: POPE RESOURCES Mailing Address: 19950 7TH AVE NE#200,POULSBO WA 98370-7405 R022 C/O OLYMPIC Ij ppl fMMl C(7U�( Vesting Codes: // L�UNI1y FLOPMFNT Location Information Legal Description: S18 T28 R1W ALL OF SECTION(LESS TAX 1&R/W)S/EASE County: JEFFERSON,WA APN: 801181001 Census Tract/Block: 9502.02/ Alternate APN: Township-Range-Sect: 28-1W-18 Subdivision: Legal Book/Page: Map Reference: 28N-1W-18-NE/ Legal Lot: Tract#: Legal Block: School District: 48 Market Area: School District Name: QUILCENE Neighbor Code: 2410 Munic/Township: QUILCENE Owner Transfer Information Recording/Sale Date: / Deed Type: Sale Price: 1st Mtg Document#: Document#: Last Market Sale Information Recording/Sale Date: I 1st Mtg Amount/Type: I Sale Price: 1st Mtg Int.Rate/Type: / Sale Type: 1st Mtg Document#: Document#: 2nd Mtg Amount/Type: / Deed Type: 2nd Mtg Int.Rate/Type: / Transfer Document#: Price Per SqFt: New Construction: Multi/Split Sale: Title Company: Lender: Seller Name: Prior Sale Information Prior Rec/Sale Date: / Prior Lender: Prior Sale Price: Prior 1st Mtg Amt/Type: / Prior Doc Number: Prior 1st Mtg Rate/Type: Prior Deed Type: Property Characteristics Year Built/Eff: / Total Rooms/Offices Garage Area: Gross Area: Total Restrooms: Garage Capacity: Building Area: Roof Type: Parking Spaces: Tot Adj Area: Roof Material: Heat Type: Above Grade: Construction: Air Gond: #of Stories: Foundation: Pool: Other Improvements: Exterior wall: Quality: Basement Area: Condition: Site Information Zoning: Acres: 635.28 County Use: DESIGNATED FOREST LAND(8800) Lot Area: 27,672,797 Lot Width/Depth: x State Use: Land Use: FOREST Commercial Units: Water Type: Site Influence: Sewer Type: Building Class: Tax Information Total Value: $1,340,340 Assessed Year: 2014 Property Tax: $827.91 Land Value: $1,340,340 Improved%: Tax Area: 301 Improvement Value: Tax Year: 2015 Tax Exemption: Total Taxable Value: $78,184 http://proclassic.realquest.com/jsp/report.jsp?&client=&action=confirm&type=getreport&... 7/23/2015 • • a%m% CROWN Crown Castle 1505 Westlake Avenue North,Suite 800 ,,® CASTLE Seattle,WA 98109 February 22,2016Parrs ,l 1PFl~►�Sr7N COUNTY DCS Jefferson County ?i' Attn: Dept.of Community Development11 FEB 2 ,‘,6 621 Sheridan Street Port Townsend,WA 98368 DP' Or t`0,1 ,SNI ` L _iOrrnrNIT RE: Eligible Facilities Request to modify equipment on a communications Tower Crown Site 826843/Crown Site Name:PT Lake Tarboo T-Mobile Site ID SEo61o6A Crown Castle on behalf of T-Mobile West LLC is submitting the attached Eligible Facilities Request application to add, remove,modify,or replace Transmission Equipment on a telecommunications Tower located at 2749 Tarboo Lake Road,Quilcene,in County of Jefferson,WA. Section 6409 of the Middle Class Tax Relief and Job Creation Act of 2012,commonly known as the"Spectrum Act" (Pub.Law No.112-96,126 Stat 156),mandates that state and local governments"may not deny,and shall approve,any eligible facilities request for a modification of an existing wireless tower or base station that does not substantially change the physical dimensions of such tower or base station." Under federal law,an Eligible Facilities Request is deemed granted sixty(6o)days after a complete application is filed with a local jurisdiction. T-Mobile proposes to modify an existing unmanned Wireless Communication Facility as follows: • This is a supplemental application to Building Permit No.BLD15-oo258 • In addition to the equipment changes under BLD15-oo258 T-Mobile proposes to remove and replace the existing antenna mounts Itemized list of submittal documents: • Cover letter • Stamped and sealed final Construction Drawings(including Site Plan) • Stamped and sealed Structural Analysis report • Building Permit Application&Supplement&Copy of Memorandum of Lease T-Mobile is committed to working cooperatively with all jurisdictions around the country to secure expeditious approval of requests to modify existing personal wireless service facilities. If you should require more information regarding the Spectrum Act,please do not hesitate to contact me with your questions. Sincerely, Aaron Hottell Real Estate Specialist I Office:206-336-3225 I Email:Aaron.Hottell@CrownCastle.com The Foundation for a Wireless World. CrownCastle.com • • 41gS°N C0 DEPARTMENT OF COMMUNITY P OMENT W 621 Sheridan Street,Port Townsend,WA 98368 t�� Tel:360.379.4450 Fax:360.379.4451 J '� _ ! Web:www.co.jefferson.wa.us/communitydevelopment E-mail:dcd a,co.jefferson.wa.us +�! ' FEB � � 2016 PERMIT APPLICATION "` PF°t OF C- MUNtTY UEVp Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -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. -This is not a standalone application; it must be accompanied by a project specific supplemental application. -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# Site Information Assessor Tax Parcel Number: 801181001 Site Address and/or Directions to Property:2749 Tarboo Lake Rd, Quilcene, WA 98376 Access(name of street(s)) from which access will be gained: Tarboo Lake Road to gravel access road Present use of property: Forest lands Description of Work(include proposed uses): This is an Eligible Facilities Request. This is a supplemental application to Building Permit No. BLD15-00258. In addition to the equipment approved under the building permit T-Mobile proposes to replace the antenna mounts. Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES NO ✓ If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: n/a Community Septic Name of System: Case#: Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: Complete _ Partial Has a reserve drainfield been designated? Yes No Date of Last Operations & Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title,which may impact the property: REVISED FEB 2 4 2016 Permit Application Page 1 of 2 JEFFERSON COUNTY DCD • • The authorized agent/representative is the primary contact for all project-related questions and correspondence. The County will mail/ e-mail requests and information about the application to the authorized agent/representative and will copy(cc) the owner noted below. The authorized agent/representative 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 iherr,rrhatlbox accepts County email(i.e.,pCounty email is not blocked or sent to junk mail ). Applicant/PropertyOwner Information ;, 1t Property Owner: I i Name: Pope Resources z Address: 19950 7th Ave NE, #200, Poulsbo, WA 98370 I 'I Phone tt: E-mail Address: ✓_ Please contact Authorized Agent/Representative with project info. (select only one). Property Owner Signature: J' --- Ac.wn Jal ll c , C{...r1-lz . j Qw'nc- Date: `2.22- 1�S Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(if other than owner) Name: T-Mobile West LLC (contact: Aaron Hottell, Crown Castle, submitting on behalf of T-Mobile) Address: 12920 SE 38th Street, Bellevue, WA 98006 Phone It E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant ✓ Name: Aaron Hottell, Crown Castle, submitting on behalf of T-Mobile Address: 1505 Westlake Ave N, #800, Seattle WA 98109 Phone tt: 206-336-3225 E-mail Address: Aaron.Hottell@CrownCastle.com Professional: - Is this an Authorized Agent/Representative for this project? NO, ✓ YES Engineer Architect ✓ Surveyor Contractor Consultant Name: Roger T. Alworth Address: 5501 NE 109th Ct #A2, Vancouver, WA 98662 Phone#: 360-885-9200 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES Engineer ✓ Architect Surveyor Contractor Consultant Name: John Welton Kelly Ill Address: 1717 S. Boulder, Suite 300, Tulsa, OK 74119 Phone If: 918-587-4630 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Attach additional pages if necessary Builders Statement The signer of this statement certifies 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: Print Name: .. Date: Fed 24 2016 Pcrmit ltion P.lgn 2 of 2 El;PERSON COt1NTY DCD • • 5 CO ,--. r--, _ .$30N ON DEPARTMENT OF COMMUNITY DEVEL a � 1 i _ V ,c4,- 4r., 6. 621 Sheridan Street,Port Townsend,WA 98368 ( n �I Tel:360.379.4450 I Fax:360.379.4451 I-' '-C Web:www.co.jefferson.wa.us/communitydevelopment F F Q ' / ,.:,1) `j E-mail:dcd n co.jefferson.wa.us `" Ii L jj l's NI NG l' SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT - '=npMENT For Department Use Only Receipt#: Date: Related Application#s: Payment#: Site Information Owner Name: Pope Resources Assessor Tax Parcel#: 801181001 Applicant:T-Mobile West LLC Type of Building New Replacement Relocated Addition Repair Demolition * *A separate permit is required Select One: Single Family Residence Modular Other WCF list Proposed Building/Project Number of floors 195'tower #new bedrooms existing total bed # new bathrooms existing total bath Heat Source Select all that apply: Electric Heating Oil Wood Propane Enter the square footage(sq/ft)that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft Residential/Commercial Main Floor Residential/Commercial Second Floor Additional Floors - heated/unheated Basement- unfinished Basement-finished space or habitable Detached Garage- heated/unheated Attached Garage- heated/unheated Garage 2nd fl- unfinished storage Garage 2nd fl-finished space or habitable Carport-2 walls or less Deck-uncovered Covered porch Other(shed, barn, pole bldg,etc.) 1600 sq.ft.compound mound Estimated Cost of Project (Required): $ 10,000 Supplemental SFR 1 FEB 2016 EFFL fzSON COUNTY DCD • • List existing buildings on property (i.e. house, garage, accessory dwelling unit,shed, barn, mobile home,other): All Existing Buildings on Property Use 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 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 of the County's intent to enter upon the property for visits related to this application and subsequent permit issuance. Aaron Hottell,Crown Castle,obo T-Mobile •� /-a Signature: Print Name: Date: Estimated Cost of Project $ 10,000 For Department Use Only Building Base Fees Building Base Plan Check Review ,l ,.1 r� l $228.00 Land Use Review EI Septic Review �,- f` $79.00 II. � _ � ,_ '1 Potable Water / $107.00 Technology/Scan F. �S( f�u�v LO?P�IENT $19.00 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach REV ' ! � Total Fees L EFFEkSU, NTY Receipt# Date: Cash/Check/CC: • • 826843 T-Mobile SE06106A 2749 Tarboo Lake Rd. .03°N cob DEPARTMENT OF COMMUNITY DEVELOPME 16 � 621 Sheridan Street,Port Townsend,WA 98368 t I 1 E `- :!7 l ti Tel:360.379.4450 Fax:360.379.4451 Web:www.co.jefferson.wa.us/communitydevelopment i E-mail:dcd n,co.jefferson.wa.us // ,1 FEB 0 t�+ FII rt G STORMWATER CALCULATION WORKSHEET Oh�t_"._ti pFV�_lOprlfNT MLA# PROJECT/APPLICANT NAME: T-Mobile 700-SE06106A-826843 DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE(I.E.,SITE) Size of parcel 635'28 acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 27,672,796 sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative)and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing,grading,filling, excavation, and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,and salal; herbaceous plants such as sword fern,foam flower,and fireweed. 4 2016 LAND DISTURBING ACTIVITY, CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/A'1LL OUN DCD Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Does the project convert 3/4 acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank, etc. sq/ft Circle: Yes No Well, utilities, etc. sq/ft Does the project convert 2'/2 acres or more of native vegetation to pasture? Driveway, parking, roads, etc. sq/ft Circle: Yes No Lawn, landscaping, etc. sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance sq/ft Cut Fill (cu/yd) Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at a n increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops,walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads, packed earthen materials, and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater. stormwater talc worksheet—REV.10/20/2014 1 • • STORMWATER CALULATIONS—IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area) sq/ft Structures(all roof area) sq/ft Sidewalks sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc sq/ft Driveway, parking, roads,etc sq/ft Other sq/ft Other sq/ft Total New n/a sq/ft Total Existing n/a sq/ft TOTAL NEW+TOTAL EXISTING* sq/ft *This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v.REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: Does the site have 35%or more of existing impervious surface? Circle: Yes No ✓ FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPS) Packet. Proponents of "medium projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal tem�lo2a4St�� ater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and • . ittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Storm water Management Manual. IJNTY IACD APPLICANT SIGNATURE By signing the Stormwater Calculation 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 7i property. j{ 1 4Giu+.t 140fia 1/, ohtp 2-22-1-6 H1 (LANDOWNER ORH UTORIZED REPRESENTATIVE SIGNATURE) M0,4,J J (DATE) l'A:P,TETt117,;"3iaF,Wkigf;;e: fWifeCTi 511VS 74:wwwitigilf4rmv03,Tinzwv1 stormwater calc worksheet—REV.10/20/2014 2 • BLD15-00258 BUILDING PERMIT APPLICN Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00258 Received Date: 7/28/2015 SITE ADDRESS: 2755 TARBOO LAKE RD QUILCENE, 98376 OWNER: T- MOBLIE PHONE: 206-336-2881 MATT ENGLESBY, PTS 568 FIRST AVE S., SUITE 650 SEATTLE WA 98104 SUBDIVISION: Block: Lot: PARCEL NUMBER: 801181001 Section: 18 Township: 28 N Range: 1V1 CONTRACTOR: TBD PHONE: 253-584-6606 REPRESENTATIVE: CROWN CASTLE ON BEHALF OF T-MOBILE PHONE: 503-709-0820 1505 WESTLAKE AVE#800 SEATTLE WA 98109 PROJECT DESCRIPTION CELL TOWER- PROCESSING AND REPLACE 3 ANTENNAS, REPLACE 1 MICROWAVE- INSTALL 3 REMOTE RADIO UNITS AND 1 BASEBAND MODULE TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: TYPE OF IMP REP MAIN: INDUSTRIAL: VALUATION 45,000.00 ADD'L: HEAT TYPE CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: NUMBER OF EMPLOYEES: WATER SYSTEM: BATHROOMS: Exist: Prop: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $532.00 SRE 07/24/15 156358 Plan Check $345.80 SRE 07/24/15 156358 State Building Code $4.50 SRE 07/24/15 156358 Total: $882.30 \\firlcmrle ring\forme\F RI Il Ann Rid rnf 7/7A/7f11F • • 4goN eo DEPARTMENT OF COMMUNITY DEVELOPMENT 6� 621 Sheridan Street,Port Townsend,WA 98368 � ti Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.Jefferson.wa.us/communitydevelopMent �� t E-mail:dcd( co.jefferson.wa.us NING,cG� PERMIT APPLICATION JUL 2 3 2015 Steps in the Permit Process: JEF[[1SOId COUNTY -Review application checklist to ensure all information is completed prior to submitting'ap.plkatiCir ITY CEyr1 0PMENT -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. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -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# Site Information Assessor Tax Parcel Number: 801181001 Site Address and/or Directions to Property:2749 Tarboo Lake Rd, Quilcene,WA 98376 Access(name of street(s)) from which access will be gained: Tarboo Lake Road to gravel access road Present use of property: Forest lands Description of Work(include proposed uses): This is an Eligible Facilities Request. T-Mobile proposes to replace (3) antennas, replace (1) Microwave, install (3) remote radio units, and (1) baseband module. Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO ✓ If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: n/a Community Septic Name of System: Case#: Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: Complete _ Partial Has a reserve drainfield been designated? Yes _ No Date of Last Operations& Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: Permit.'pp icattol,Page 1 of 2 • The authorized agent/representative isTl'fe primary contact for all project-related questions and correspondence. The County will mail/ e-mail requests and information about the application to the authorized agent/representative and will co. ner noted below. The authorized agent/representative is responsible for communicating the • • ::. • .I d ith the application. It is the responsibility of the authorized agent/representative and owi cfi ;lt elb�� o my email(i.e., County email is not blocked or sent to "junk mail"). Applicant/Property Owner Information \ Property Owner: UL Name: Pope Resources 3 Address: 19950 7th Ave NE, #200, Poulsbo, WA 98370 1 i Phone#: E-mail Address: ✓_ Please con t Authorized Agent/Representative with project info. (select only one). Property Owner Signature. 71vty: , c�vim , S t�z Date: (71 47,7) Note: For projects with multiple owners,attach a sep e sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(If other than owner) Name: T-Mobile West LLC (contact: Tina Hwang, Crown Castle, submitting on behalf of T-Mobile) Address: 12920 SE 38th Street, Bellevue, WA 98006 Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant ✓ Name: Tina Hwang, Crown Castle, submitting on behalf of T-Mobile Address: 1505 Westlake Ave N, #800, Seattle WA 98109 Phone#: 206-336-2881 E-mail Address: Tina Hwang@CrownCastle.com Professional Is this an Authorized Agent/Representative for this project?' NO YES Engineer Architect ✓ Surveyor Contractor Consultant Name: Roger T. Alworth Address: 5501 NE 109th Ct #A2, Vancouver, WA 98662 Phone#: 360-885-9200 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO / YES Engineer 1 Architect Surveyor Contractor Consultant Name: John Welton Kelly Ill Address: 1717 S. Boulder, Suite 300, Tulsa, OK 74119 Phone#: 918-587-4630 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO ! YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Attach additional pages if necessary Builders Statement The signer of this statement certifies 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: Print Name: Date: 1'e,mir;Applicari;n:Pagc 2 o12 • 450N c DEPARTMENT OF COMMUNITY DEVELOPMENT °r✓. 621 Sheridan Street,Port Townsend,WA 98368 44, Tel:360 379.4450 Fax:360.379.4451 u ti �C Web:www.co.jefferson.wa.us/communitydevelopment } I!, E-mail:dcdaco.jefferson.wa.us i �ti i N0,s9 SUPPLEMENTAL APPLICATION JUL 2 3201 ,�I RESIDENTIAL OR COMMERCIAL BLDG PERMITrte�7 -�;y oro'rhT For Department Use Only Receipt#: date. Related Application#s: Payment#: Site Information Owner Name: Pope Resources Assessor Tax Parcel#: 801181001 'Applicant:T-Mobile West LLC Type of Building New Replacement Relocated Addition Repair Demolition *A separate permit is required Select One: Single Family Residence Modular Other WCF list Proposed Building/Project Number of floors 195'tower #new bedrooms existing total bed # new bathrooms existing total bath Heat Source Select all that apply: Electric Heating Oil Wood Propane Enter the square footage(sq/ft)that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft Residential/Commercial Main Floor Residential/Commercial Second Floor Additional Floors- heated/unheated Basement-unfinished Basement -finished space or habitable Detached Garage- heated/unheated Attached Garage- heated/unheated Garage 2nd fl- unfinished storage Garage 2nd fl-finished space or habitable Carport-2 walls or less Deck-uncovered Covered porch Other(shed, barn, pole bldg,etc.) 1600 sq.ft.compound 1600 sqft.compound Estimated Cost of Project(Required): $ 45,000 Supplemental Silt 1 110 1110 List existing buildings on property (i.e. house, garage,accessory dwelling unit,shed, barn, mobile home,other): All Existing Buildings on Property Use By signing this application form, the owner/agent attests that the information provided herein, and arty pttaclirpents; i true and correct to the best of his, her or its knowledge. Any material falsehood or any omission Of a material fact rn 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 wrl`436$61-6:901 F,,T in compliance with all applicable federal, state and county laws and regulations and I agree2to p?ov')de_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 rel ted to this application and subsequent permit issuance. Signature: `e _ Print Name: Tina Hwang,Crown Castle,obo T-Mobile Date: r'Y1 :1-°1 c Estimated Cost of Project $ 45,000 For Department Use'Only " , Building Base Fees Building Base Plan Check Review Land Use Review $228.00 Septic Review $79.00 Potable Water $107.00 Technology/Scan $19.00 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt# Date: Cash/Check/CC: • • 826843 T-Mobile SE06106A 2749 Tarboo Lake Rd. 40N e DEPARTMENT OF COMMUNITY DEVELOPM ,Cz� �. 621 Sheridan Street,Port Townsend,WA 98368 C W C Tel:360.379.4450 Fax:360.379.4451 �� --"- Web:www.co.jefferson.wa.us/communitvdevelopment E-mail:dcd(t�,co.jefferson.wa.us �! r� r!! I N— STORMWATER CALCULATION WO . K .,• (-71-!.: ,vN rte. • MLA# PROJECT/APPLICANT NAME: T-Mobile.700-SEO61O6A-826843 DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE(I.E.,SITE) Size of parcel 635.2$ acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 27,672,796 sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative)and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing,grading,filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds, that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,and salal; herbaceous plants such as sword fern,foam flower,and fireweed. LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE.VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Does the project convert 3/4 acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank,etc. sq/ft Circle: Yes No Well, utilities,etc. sq/ft Does the project convert 2'/2 acres or more of native vegetation to pasture? Driveway, parking, roads, etc. sq/ft Circle: Yes No Lawn, landscaping, etc. sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance sq/ft Cut Fill (cu/yd) Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops,walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads, packed earthen materials, and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater. stormwater talc worksheet—REV.10/20/2014 1 iil'i nsFIC._ LT____;c=7' i 'V E �1, -• ___,, , r J _ 13 STORMWATER CALULATIONS–IMPERVIOUS SURF CE �'t JEFFERSON COUNTY NEW EXISTING um-OF COVII,UNI T`!DF``';PFErT Structures(all roof area) sq/ft Structures(all roof area) sq/ft Sidewalks sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads,etc sq/ft Driveway, parking, roads,etc sq/ft Other sq/ft Other sq/ft Total New n/a sq/ft Total Existing n/a sq/ft TOTAL NEW+TOTAL EXISTING* sq/ft *This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v.REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: % Does the site have 35%or more of existing impervious surface? Circle: Yes No FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of "medium" projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Storm water Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation 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. -----` __ , I/Z-- (LANDOWNER O• REPRESENTATIVE SIGNAT ,ORt„f ni.,1� fri• r� ATE) stormwater calc worksheet—REV.1020/2014 2 Parcel Details • Page 1 of 2 40 1 -s— , ' e erson outi i f i. d *" --- #her Stalion k Database Toots 17_, lame County info Departments t ears I i Parcel Number: 801181001 SEARCH Parcel Number: 801181001 Printer Friendly Owner Mailing Address: POPE RESOURCES C/O OLYMPIC RESOURCE MGMT ATTN: LAND RECORDS 19950 7TH AVE NE #200 POULSBO WA98370 Site Address: 2755 TARBOO LAKE RD QUILCENE 98376 Section: 18 School District: Quilcene (48) Qtr Section: NE1/4 Fire Dist: None Township: 28N Tax Status: Taxable Range: 1W Tax Code: 0301 Planning area: Quilcene (10) Sewer: Drainage: Bank: View 1: View 2: Zoning 1: CF-80 - Commercial Forest Zoning 2: Zoning 3: Sub Division: Assessor's Land Use Code; 8800 - Designated Forest Land 9100 - Vacant Land Property Description: S18 T28 R1W ALL OF SECTION(LESS TAX 1 & R/W) S/EASE Tax, A/V, Sales, Photos, and Permit Data Bldg Data Map Parcel Plats&Surveys Septic Monitoring Info HOME I COUNTY INFO I DEPARTMENTS I SEARCH Best viewed with Microsoft Internet Explorer 6.0 or later Windows- Mac http://www.co.jefferson.wa.us/assessors/parcel/parceldetail.asp?value=801181001 7/28/2015