HomeMy WebLinkAboutBLD2015-00234 - 01 PERMIT APPLICATION °BUILDING PERMIT APPLIC•ON BR view T pe:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00234 Received Date: 7/9/2015
SITE ADDRESS: 2805 LARSON LAKE RD
OWNER: T-MOBILE WEST LLC CROWN CASTLE PHONE: 206-336-2881
1505 WESTLAKE AVE N #800
SEATTLE WA 98109
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801122002 Section: 12 Township: 28 N Range: 1V\
CONTRACTOR: TBD PHONE: 253-584-6606
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP REPLACE 3 ANTENNAS, REMOVE 3 TMA'S INSTALL, 3 FRLB
RADIOS, 2 FXFC, 1 FXFC, 1 FBBC, 1 FSMR AND 1 ESMB.
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP ALT INDUSTRIAL:
VALUATION 45,000.00 MAIN:
CODE EDITION: 2012 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
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 07/09/15 156236
Plan Check $345.80 SRE 07/09/15 156236 APPROVED
State Building Code $4.50 SRE 07/09/15 156236 JUL V
Total: $882.30 Z 1 2015
Jefferson County DCG
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QUILDING PERMIT APPLICASN BL
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00234 Received Date: 7/9/2015
SITE ADDRESS: 2805 LARSON LAKE RD
CHIMACUM, 98325
OWNER: T-MOBILE WEST LLC CROWN CASTLE PHONE: 206-336-2881
1505 WESTLAKE AVE N #800
SEATTLE WA 98109
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801122002 Section: 12 Township: 28 N Range: 1V1
CONTRACTOR: APPLE ROBERT PHONE: 866-545-1782
1825 PONCE DE LEON BLVD
CORAL GABLES FL 33134
Contractor's License BRUBAAJ868QF Expires 4/10/2016
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION REPLACE 3 ANTENNAS, REMOVE 3 TMA'S INSTALL, 3 FRLB
R' II • FXFC, 1 FXFC 1 FBBC 1 FSMR AND 1 ES
REVISION SUBMITTED TO ADD RELOCATE 1 EXISTING MICROWAVE-
1 NEW MICROWAVE - REMOVE 1 EXISITNG PLATFORM- INSTALL 3
` NEW ANTENNA MOUNTS.
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP ALT INDUSTRIAL:
VALUATION 45,000.00 MAIN:
CODE EDITION: 2012 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS: KeLyl.s i 0, , 1
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $532.00 SRE 07/09/15 156236
Plan Check $345.80 SRE 07/09/15 156236
Consistency Review $234.00 SRE 07/09/15 156236
Scanning Fee $19.50 SRE 07/09/15 156236
State Building Code $4.50 SRE 07/09/15 156236
Plan Check $85.00 SRE 03/09/16 162672
Cnnsi tenry Review $85 00 SRF 03/09/16 162672
Total: $1,305.80
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•
$ON o� DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
Tel:360.379.4450 Fax:360.379.4451
Web:www.co..efferson.wa.us communit develo sment aC�(/
E-mail:dcd(n�co.jeffersan.wa.us
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1SkI N
2015
,.
PERMIT APPLICATIO }�L 9 VP
Steps in the Permit Process: FfFERSON00011 p rfNT
-Review application checklist to ensure all information is completed prior to sub itting a lli tjc�t�,IT D„cr."`0'
-Make sure septic has been applied for and water availability has been proven. ipFF
_.__..,�...
-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: 801122002
Site Address and/or Directions to Property:2805 Larson Lake Road, Port Ludlow,WA 98365
Access (name of street(s)) from which access will be gained: Larson Lake Road to existing dirt 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, remove (3) TMAs,
install (3) FRLB radios, (2) FXFC, (1) FBBC, (1) FSMF and (1) ESMB.
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:
r •
The authorized agent/representative is the primary contact for all project-related questions an. : „ r r - 'au , will
mail/ e-mail requests and information about the application to the authorized agent/re.. - e1441, 'F- ., :6,,,i.. opy(cc) the owner
noted below. The authorized agent/representative is responsible for communicating t '.. ori-fo all parties involved with
the application. It is the responsibility of the authorized agent/representative and owne p lie their mailbox accepts County
email((i.e., County email is not blocked or sent to "junk mail"). _
Applicant/Property Owner Information --�''J `�
Property Owner: \ \ '
Name: Pope Resources ��,- - I
,�0,,�
Address: 19950 7th Ave NE, #200, Poulsbo, WA 98370 Cao,T...
Phone#: _ E-mail Address:
✓ Please cont ct Authorized Agent/Representative with project info. (select only one).
Larksw
Property Owner Signature. t T / 1rrt C+IC' o �Da ii 77e20S—
Note: For projects with multiple owners,attach a se a sheet with each owner s)information and signatures. 0°1-)
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: Brian Kenneth Kermode r�
Address: or e fr„,s, " e2 r C�Ct S`� - S(.l.,l to 1000 CO 1 UsAOWS Oh 1a2
Phone#: ' t — — . , E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES
Engineer Architect ✓ Surveyor Contractor Consultant
_
Name: Vlad Diaconu -Cvnpt,ov.i. 0
Address: LH j , Fcidtr't"cam (M e/ C( - Sude . 5)b 6*.iue Wye Lic:‘
Phone#: 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:
Permit Application Page 2 of 2
• •
¢SoN , DEPARTMENT OF COMMUNITY DEVELOPMEN ‘,\
� 621 Sheridan Street,Port Townsend,WA 98368 �0 '•\
'Tel:360.379.4450 I Fax:360.379.4451
Web:www.co.jefferson.wa.us/communitydevelopment r41�
E-mail:dcdna,co.jefferson.wa.us \� � ,
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� HINo�o SUPPLEMENTAL APPLICATION \`
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt#: Date:
Related Application#s: Payment#:
Site Information
Owner Name: Pope Resources Assessor Tax Parcel#: 801122002
'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 198 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.) 3600 sq.ft. 3600 sq.ft.
Estimated Cost of Project (Required): $ 45,000
•
List existing buildings on property (i.e. house,garage, accessory dwelling unit,shed, barn, mobile ho ;ot. €f �
All Existing Buildings on Property Use � `� `"�-'' ‘
`)
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By signing this application form, the owner/agent attests that the information provided herein, and in any attachment , 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.
Tina Hwang,Crown Castle,obo T-Mobile
Signature. ' Print Name: Date: iii/ 0i, """'
Estimated Cost of Project $ 45,000
For Department Use Only
Building Base Fees
Building Base 5 3 2_ ' v°
Plan Check Review `J- e)U
Land Use Review –$22-8.00 . Z' 1-4 'uL)
Septic Review $7 —
Potable Water
Technology/Scan $ _ � 1 ..5 1)
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees ` I �S C)
Receipt# Date: Cash/Check/CC:
• .
ELIGIBLE FACILITIES REQUEST CERTIFICATION FOR NON- _ :,110, of E
CHANGES -
TO A WIRELESS TOWER NOT LOCATED WITHIN A PUBLIC ' 11 OF WAY ,
I UL _ g115 'i
1) Address of the Wireless Tower: _2805 Larson Lake Rd., Port Ludlow 6 $42 _
PITY
2) The height(measured in feet above ground level) of the existing Tower as original yl err ,L______--,7,-:--7,
,, <<n o°2.��
approved, including any modifications approved prior to February 22, 2012: 1'98'2` - r
3) What is the height(measured in feet above ground level) at which the modifications to the
Transmission Equipment will occur on the Tower? 195'
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? 198'
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?
(l 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?
❑ Yes ® 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 M 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?
❑ Yes M 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?
fYes ® 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 ® 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 7 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
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4–SON e0 DEPARTMENT OF COMMUNITY DEVELOPM
44, a 621 Sheridan Street,Port Townsend,WA 98368 uL1T92015 /
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Web:www.co.Jefferson.wa.us/communitydevelopment
E-mail:dcd a,co.jefferson.wa.us41 IN— T JEFFERSON COUNIY
--Q P OF COP���UNITy DEVELOPMENT
STORMWATER CALCULATION WORKSHEET
MLA# PROJECT/APPLICANT NAME:
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 260.52 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 1 ,348,251 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%acres or more of
native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft t
Circle: Yes .I)
Lawn, landscaping, etc. sq/ft
Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 0 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
• •
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: 0/0
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.
,Growti. CQ.sYte, otoo 7/7,(�/.c
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(LANDOWN R OR AUTHORIZED R 'RESEN ATIVE SIGNATURE) � ^ii/ (D E)
8. t .t�''V
S 0 C'
stormwater calc worksheet—REV.10/20/2014 2
',BUILDING PERMIT APPLIC•ON Re De 5-0 pe: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00234 Received Date: 7/9/2015
SITE ADDRESS: 2805 LARSON LAKE RD
CHIMACUM, 98325
OWNER: T-MOBILE WEST LLC CROWN CASTLE PHONE: 206-336-2881
1505 WESTLAKE AVE N #800
SEATTLE WA 98109
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801122002 Section: 12 Township: 28 N Range: 1V1
CONTRACTOR: APPLE ROBERT PHONE: 866-545-1782
1825 PONCE DE LEON BLVD
CORAL GABLES FL 33134
Contractor's License BRUBAAJ868QF Expires 4/10/2016
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION REPLACE 3 ANTENNAS, REMOVE 3 TMA'S INSTALL, 3 FRLB
RADIOS, 2 FXFC, 1 FXFC, 1 FBBC, 1FSMR AND 1 ESMB.
REVISION SUBMITTED TO ADD RELOCATE 1 EXISTING MICROWAVE-
1 NEW MICROWAVE - REMOVE 1 EXISITNG PLATFORM- INSTALL 3
NEW ANTENNA MOUNTS.
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP ALT MAIN: INDUSTRIAL:
VALUATION 45,000.00 ADD'L: HEAT TYPE
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS: cPelltsi.olc .
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $532.00 SRE 07/09/15 156236
Plan Check $345.80 SRE 07/09/15 156236
Consistency Review $234.00 SRE 07/09/15 156236
Scanning Fee $19.50 SRE 07/09/15 156236
State Building Code $4.50 SRE 07/09/15 156236
Plan Check $85.00 SRE 03/09/16 162672
ConsistPnry Review $85 00 SRF O'V0Q/16 162672
Total: $1,305.80
\\4iriomnrlr\r nfo\fnrmc\F PI fl Ann PIA rn4 4/Q/9(118
BLD15-00234
UILDING PERMIT APPLICAN Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00234 Received Date: 7/9/2015
SITE ADDRESS: 2805 LARSON LAKE RD
OWNER: T-MOBILE WEST LLC CROWN CASTLE PHONE: 206-336-2881
1505 WESTLAKE AVE N #800
SEATTLE WA 98109
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801122002 Section: 12 Township: 28 N Range: 1V\
CONTRACTOR: TBD PHONE: 253-584-6606
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION REPLACE 3 ANTENNAS, REMOVE 3 TMA'S INSTALL, 3 FRLB
RADIOS, 2 FXFC, 1 FXFC, 1 FBBC, 1 FSMR AND 1 ESMB.
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP ALT MAIN: INDUSTRIAL:
VALUATION 45,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 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 07/09/15 156236
Plan Check $345.80 SRE 07/09/15 156236
State Building Code $4.50 SRE 07/09/15 156236
Total: $882.30
II
\\firlomnrL\rhfo\forme\F RI n Ann PH rnf 7/0/9(11F
• •crown Castle
CROWN 1505 Westlake Avenue North,Suite 800
CASTLE CrSeattle, WA 98109
July 7,2015
Jefferson County
Attn: Dept.of Community Development II
621 Sheridan Street
Port Townsend,WA 98368
RE: Eligible Facilities Request to modify equipment on a communications Tower
Crown Site 826842/Crown Site NamePT Hwy 19(Beaver Vly)
T-Mobile Site ID SEo61o2B
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 2805 Larson Lake
Road,Port Ludlow,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:
• Replace(3)antennas,remove(3)TMAs,install(3)FRLB radios,(2)FXFC,(1)FBBC,(1)FSMF and(1)ESMB
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
• 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,
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
• •
4S0N Co�� DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
./
Tel: Fax:360.379.4451
Web:www.co..efferson.wa.us communitvdevelo ment
E-mail:dcdaco.jefferson.wa.us
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PERMIT APPLICATIOl v-\\\, ��� -
Steps in the Permit Process:
EFFERS Cr COUNTV M1F�iT
-Review application checklist to ensure all information is completed prior to sub ittingap i !1"
-Make sure septic has been applied for and water availability has been proven. DEPp� j,�gp',
-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 its: MLA#
Site Information
Assessor Tax Parcel Number: 801122002
Site Address and/or Directions to Property:2805 Larson Lake Road, Port Ludlow,WA 98365
Access(name of street(s)) from which access will be gained: Larson Lake Road to existing dirt 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, remove (3) TMAs,
install (3) FRLB radios, (2) FXFC, (1) FBBC, (1) FSMF and (1) ESMB.
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:
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The authorized agent/representative is the primary contact for all project-related questions an. :r,., c • e a t�will
mail / e-mail requests and information about the application to the authorized agent/re. - e.e�,g1 ,- " spy(cc) t , 7her
noted below. Tlie authorized agent/representative is responsible for communicating t ... orr o all parties mvo(ved`tiyrch
the ap lication. It is the responsibility of the authorized agent/representative and owne,''p .ure their maull'Ll`
oxna,aciepts(,oitnt�y
email (i.e., County email is not blocked or sent to "junk mail"). \ \ �`, — -' "
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Applicant/Property Owner Information \\c\-\\\t., /i
Property Owner:
Name: Pope Resources
Address: 19950 7th Ave NE, #200, Poulsbo, WA 98370
Phone#: E-mail Address:
✓ Please cont ct Authorized Agent/Representative with project info. (select only one).
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Property Owner Signature. --n-v,„- .}.�„ , 1.31.,.., 1.31.,..,, 4Q4-it e� Date: 7/"1/ `2Z)/e;"
Note: For projects with multiple owners,attach a se e sheet with each owners)information and signatures( /4°1)
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: Brian Kenneth Kermod��e,
Address: , C ct5 V rbact sr , S(,1 e tope) Co 1 uykrxcs Oh 14;24 '"---
Phone#: ‘ — ..,, — -_ r' E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO ✓ YES
Engineer Architect ✓ Surveyor Contractor Consultant
Name: Vlad Diaconu � c'cl
Address: Li-) F-6(krt c pyiv C( Su)i-Fe - t '..)utf vdi4 ciS
f
Phone#: 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:
Pcmut,AitrIication p.._2 of 2
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gory c DEPARTMENT OF COMMUNITY DEVELOPMEN
e,. 621 Sheridan Street,Port Townsend,WA 98368
Tel:360.379.4450 Fax:360.379.4451 e
tiWeb:www.co.Jefferson.wa.us/communitydevelopment
L-mail:dcd a,co.jefferson.wa.us -� A
IrSNI N G 101 SUPPLEMENTAL SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt#: \ ‘-Date:
Related Application#5: Payment#:
Site Information
Owner Name: Pope Resources Assessor Tax Parcel It: 801122002
Applicant:T-Mobile West LLC
Type of Building
New Replacement yg Relocated
Addition Repair Demolition
*A separate permit is required
Select One:
Single Family Residence Modular Other WCF list
Proposed Building/Project
Number of floors 198'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.) 3600 sq.ft. 3600 sq.ft.
Estimated Cost of Project (Required): $ 45,000
• •
List existing buildings on property (i.e. house,garage,accessory dwellin• unit, shed, barn, mobile ho y &/
All ExistingBuildings on Property Use SC; �'�,
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By signing this application form, the owner/agent attests that the information provided herein, and in any att'OGhraerntis1
true and correct to the best of his, her or its knowledge. Any material falsehood or any omissio of a tate�`tal,fadf made
by the owner/agent with respect to this application packet may result in making any issued perm't_nulFand 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.
Signature. Print Name: Tina Hwang,Crown Castle,obo T-Mobile Date:
Estimated Cost of Project $ 45,000
For Department Use Only
Building Base Fees
Building Base 5 3 2- vc)
Plan Check Review 'J 8U
Land Use Review
Septic Review "'$79766--
Potable Water $ —
Technology/Scan
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees `" 1 \ - BO
Receipt# Date: Cash/Check/CC:
� 2� R-1°1/1/l 6c1b--
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ELIGIBLE FACILITIES REQUESTATION FOR NON- _ : >�7 E
CHANGES
TO A WIRELESS TOWER NOT LOCATED WITHIN A PUBLIC ' ' OF WAY
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9 X015 '1
1) Address of the Wireless Tower: _2805 Larson Lake Rd., Port Ludlow 820,842) _
U Li I-- ---r
2) The height(measured in feet above ground level) of the existing Tower as ,riginally Il r';,,U tr. v r orngs�aT
approved, including any modifications approved prior to February 22, 2012: 1198';„------F r��
3) What is the height(measured in feet above ground level) at which the modifications to the
Transmission Equipment will occur on the Tower? 195'
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? 198'
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?
n Yes N 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 ® 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 ®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?
Yes N 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?
Fl Yes Fl No
Non-Substantial Change Certificate for Towers Not Within A Public Right of Way
National Development 2015.3
ill
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9) Will the proposed modification in Transmission Equipment defeat the existing concealment
elements of the Tower?
n Yes I 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 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?
❑ Yes ❑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 7 day of July, 2015.
Signature 2-5
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
8'2.6.8112.
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DEPARTMENT OF COMMUNITY DEVELOPME � i
621 Sheridan Street,Port Townsend,WA 98368 JUL - 1r ��
ti
"I'el:360.379.4450 lax.360.379.4451 �� I �
Web:www.co.jefferson.wa.us/communitydevelopment
F,-mail dcd(c8,co.jefferson.wa.us IE��LP,SO.�' UUfd1Y
NC;C(5�
STORMWATER CALCULATION WORKSHEET
MLA# PROJECT/APPLICANT NAME:
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 260.52 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 1 1,348,251 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'/2 acres or more of
native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft
Circle: Yes N
)-rc
Lawn, landscaping, etc. sq/ft
Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 0 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
• •
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 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.
A-ft ,G,0-wt. 4st-1e, ole `7'/11-0r
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(LANDOWN R OR AUTHORIZED R RESEN ATIVE SIGNATURE) 1�r!/I" (D E)
Mq.. EDIUI f. [sGE 'RP.gtOPMENT. •
stormwater calc worksheet—REV.10/20/2014 2