HomeMy WebLinkAboutBLD2015-00233 - 01 PERMIT APPLICATION BLD 15-00233
BUILDING PERMIT APPLICATIOIS Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00233 Received Date: 7/9/2015
SITE ADDRESS: 263 KALA HEIGHTS DR
OWNER: BARBARA DAWSON PHONE: 360-316-9472
ROBERT J LONGMIRE
263 KALA HEIGHTS DR
PORT TOWNSEND WA 98368-9506 9658 - KALA HEIGHTS PUD A&B
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 965800010 Section: 27 Township: 30 N Range: 11/1
CONTRACTOR: INTEGRITY HOMES & REMODELING PHONE: (360) 316-9472
124 SWANSON AVE
PORT TOWNSEND WA 98368
Contractor's License INTEGHR953PD Expires 10/4/2015
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI\ NEW DECK- ON EXISITNG HOME
SEP92-00378
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 6,586.00 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: 332
BANK HEIGHT:
SEWAGE DISPOSAL: CMY
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $124.00 SRE 07/09/15 156234 APPROVED
Plan Check $80.60 SRE 07/09/15 156234
State Building Code $4.50 SRE 07/09/15 156234 AUG 0 5 2015
Total: $209.10
Jefferson County DCG
\lfirlom ar4\rinfoUnrmc\F RI fl Ann RI•I rni 7/0/7R1
f
1 10 IUD) 5- 00.3
�g°N cow DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
.-4 TT-
Tel 360.379.4450 ( Fu:360.379A-151
r
Web:aww.co.Jefferson.wa.us/communitydevelopment i1
E-mail:dc4tico.lefferson.wa.us i i //'
� �f
PERMIT APPLICATION ' H JUL - 8 2015 1
■
Steps in the Permit Process: -OfPT.OF�OMA-"CpuN�jl,_J
-Review application checklist to ensure all information is completed prior to submitting applicatio UNIryO
-Make sure septic has been applied for and water availability has been proven. f�FI�MfP17
-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#5: MLA#
i Site Information
Assessor Tax Parcel Number: '16-5. F'Q 0(9 l 0 /�
Site Address and/or Directions to Property: 2.63 k 1(c 04._?c, it b. Drly.C_ (kct 1q Po ts�-)
Poi-+. WW1S.2:nci E (!m IS' 3EaY ./
Access (name of street(s)) from which access will be gained:
Present use of property: 5. F.
Description of Work(include proposed uses): Add dock
1
Wastewater-Sewage Disposal j
This property is served by Port Townsend of Port Ludlow sewer system? YES NO vr-
If not served by sewer identified above,identify type of septic system below:
Type of aWage System Serving Property:
Septic Septic Permit#: 54 9 Z ^ 0037 F V Community Septic Name of System: k4' /AIM- L (o -/y Case #:
Are other residences connected to the septic system? l
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: /0/4 / 20/ (( Attach last report to application
Describe or attach any drainfield easements,covenants or notices on title,which may impact the property:
Y • •
The authorized agent/representative is the ptimary contact for all project-related questions and correspondence. The County aril[
mail /e-mail requests and information about the apphcation to the authorized agent/representative and will copy(cc)the owner
noted below. The authorized agent/representative is responsible for communicatmgthe information to all parties utvolved with
the Application. It is the responsibility of the authorized agent/representative and owner to ensute their machos accepts County
email fie,&.aunty email is not blocked or sent to"tunic mai[°i
Applicant/Property Owner Information
Property Owner.��1t `` l
Name: I.3C,r-Ytara Dcwjc.', �t- nkzrI _ Lovri'+t[.-t-
' Address: `.«3 kode li�q�rf-s OR rflri-7n ns...g_ it;A 530'
Phone*: — 3&v-- 3`,/cf_ 2b3' / E-mai1Address: bcbp I..cwrjtwdrL .ur'Y�
/ Please contact , ,.rued Agent/Representative with project info.(select'only one). JJ _
7`Property Owner Signature: �.���ra ' r`.,f...-- a Date:6/5W .p I.S
t lb
Note: For projects with mukiple earners,attach a • cheat wide • ownstsilallorreetket aod stOraturas.
LAppliont Authorized (imam 1111110111111)
Name: ira n:d Lf C )4c.✓■
Address: 11 4-i SWc.as,.. Avt- , ' L "TN..,A.S t 6.‘c.;
, /AM 15 36.5"
Phone a: "CG . 3 (,.-Ctj72_ E-mail Address: ,n1151r;j19/..41 r.y 4j cAJt/i. 4.4 cal
Professional Is this an Authorized Agent/Representative for this project? NO YES
Engineer _ Architect J_ Surveyor 7< Contractor Consultant
Name: }r„M.- G5 q*e L'-a -
Address
i
Phone N: E-mail Address:
Professional- Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant
Name:
Address:
Phone II: E rtwil Address:
Professional Is this an Authorized Agent/Representative for this project? NO YES
Engineer _ Architect Surveyor Contractor Consultant
Name:
Address:
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 the will be assuming the responsibility-o-f the General Contractor for the proposed project. E
_- i . T Print Name:ZO6eC� t"i rt. _ Date: 6/30/7.0i-c-- `
Signarure� .i' `_�__
. •
SON cQ DEPARTMENT OF COMMUNITY DEVELOPMENT
�fV 621 Sheridan Street,Pan Townsend,WA 98368 _ ------
2 Tel 360.379.4450 Fam 360.379.4151 n t= fi
ti e< web:www.co.jeffersoawa.uslcomxnunitydecefopment I
E-mail dcd a co.jefferson.wa.us
�is JUL - 8 2015
9shtN6SO SUPPLEMENTAL APPLICATION j; I� L!J f
RESIDENTIAL OR COMMERCIAL BLDG PERMIT �
JEFFEP o a COUNTY
CEPT r= MI ^�IiYDEVE1OPMENT
For Department Use Only Receipt#: --fla
Related Application#s: Payment#:
Site Information
Owner Name: ea r-w °OJAI jc. -t Assessor Tax Parcel#: q6 5$00O ti 0
RobM4 Lov.3 vt ir-e_
Type of Building
New Replacement Relocated
Addition Repair Demolition
�jc dam` - -FFro A+ of 4- �I 'A separate permit is required
Select One: ('C r °'"ae- a °°'r'
RV
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors #new bedrooms existing total bed
#new bathrooms existing total bath
Heat Source
Select all that apply:
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor 2 2, (t{
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement-unfinished
Basement-finished space or habitable
Detached Garage-heated/unheated
Attached Garage- heated/unheated (?24.1
Garage 2nd fl- unfinished storage
Garage 2nd fl-finished space or habitable
Carport-2 walls or less
Deck-uncovered a0 3 3 2 (475$.p-
Covered porch I ( 0
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ 000.Cr°
•
SON c DEPARTMENT OF COMMUNITY DEVELOPMENT
4c-c,"
C7� 621 Sheridan Street,Port'lownsend,WA 98368
1j Tel 360 379 4450 I Fax 360379 4451
C Web ww .co.Jefferson wa.us/commurutydevelopment
E-mail:dcd�a co jefferson.waus
�sI11 NG v SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt#: Date:
Related Application#s:, Payment#:
Site Information
Owner Name: Assessor Tax Parcel #:
Type of Building
New Replacement Relocated
Addition Repair Demolition *
*A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors # 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 ICC Valuation (Office Use)
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.)
Estimated Cost of Project (Required): $ $
Supplunurtil si R 1
• •
List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All Existing Buildings on Property Use
17,
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:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent
with respect t this application packet ma ult in making any issued permit null and void.
g r�C� i-4� -)7q. /ts
Signature: Print Name: to 4r t. Date:
ForDepartment
Building Permit Fees
Building Base 111-i O°
Plan Check Review V3. ?()
Land Use Review $234.00
Septic Review $129.00
Potable Water 98—•
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Total Fees 5C)1
Receipt# Date: Cash/Check/CC:
Si,,�kniaral�I'R 2
• •
Jefferson County Public Utility District Of
230 Chimacum Rd 360-301-0249
Chimacum. WA 98339
' 1 ` PROPERTY INFORMATION
263,257,235,201&193 kola heights
\ '
Location:263 KALA HEIGHTS DR
1, 2015 ' I port townsend
V� 8 ', LI Tax ID:965800010
Mall To: PAUL FRENZEN
263 KALA HEIGHTS DR - Use:Residential,Multi Family
PORTTOWNSEND,WA iEFF LSONCO Y
PORT 506 "F CO I lNl?Y C ""1 °M ^T System Design Flow:1800
GENERAL SYSTEM TYPE:PUMP TO GRAVITY
Owner.PAUL FRENZEN
ON ID:SOM92-00378
Fad ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT Fdd
Here Here 10/06/2014 - Inspection Type:ROUTINE - Correction Status:Some Correctlons Made �
Company. Ilk ik Performed By: Submitted 10/06/2014 by:
Jefferson County Public Utility District#1 Randy Calkins Randy Calkins
This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development.
COMMENTS&GENERAL INSPECTION NOTES
Deficiencies Noted:deficiencies must be corrected to ensure proper k,Trtovi+t'r r ntP Orrsire SP wage Sys ter.
At#257 kola heights dr I could not access the lids without the help of the homeowner holding the plants back while I inspected.Heather bushes
need to be trimmed back before the next inspection.
At#263 kale heights dr the fir tree that was growing into the septic tank has been cut down.The rhody bush is still growing roots into the tank al
the inlet pipe.It needs to be removed.The septic tank
lids cannot be covered by bark.
GENERAL SITE 8.SYSTEM CONDITIONS
The General Site and System Conditions were: Fully Inspected
All Components accessible for maintenance,secure and in good condkixr: NO - --
Surfacing effluent fromany component(including mound seepage): NO
Components appear to be watertight-no visual leaks: YES
Improper encroachment(roads.buildings.etc.)onto component(s): NO
Component settling problems observed: NO
Abnormal ponding present for one or more of the disposal components: NO
Subsurface components adequately covered YES
Owner compliance issues noted YES
Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: YES
Occupant compliance problem(occupant not operating the system properly). If YES,describe in notes: NO
If deficiencies were identified on last inspection were they corrected before or during this inspection? NO Iicrent
(If NO,describe in notes,NA=no deficiencies on last report):
OSS Components,structures and appurtenances located per as-diVremrd drawing 01NO,describe YES
in notes). If no as-buil exists or changes made,stale NO and provide record to Heakh Dept:
Alterations made to the OSS(valves adjusted,timer settings modified,pods irnsfaled,etc.)(If YES, NO
describe in notes):
The house/structure was vacant or used infrequently,assessment of the drenrrfieW was not possible NO
Is the SEP case in a finaled/completed status?(if NO explain in comments) -_-- _-- YES ___-- - -
ONSITE SEWAGE SYSTEM INSPECTION DETAIL
TANK:Septic Tank•2 Compartment 263 KALA HEIGHTS
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits pf NO explain in comments): YES
Alt required baffles in place(N/A=No baffles required): YES
Effluent Fitter Cleaned(N/A=Not Present): N/A
Effluent filter/screen needed cleaning on arrival N/A
Compartment 1 Scum accumulation(Inches,if other specify): 0
Compartment 1 Sludge accumulation(Inches,k other specify): 6
Misreport Indkewe certain el recfa/s&s°Mle mste sewer system at the Yo ea'asrin no ways the report a guarantee of operalgn crMee polwneno.
ReportlD:401615 View inspection reports online at vxrw.onlinerme.com Page 1 of 3
Compartment 2 Scum accumulation(Inches,if other ): 0
Compartment 2 Sludge accumulation(Inches,if other specify): -2
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper:
TANK:Septic Tank-2 Compartment 257 KALA HEIGHTS
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits(if NO explain in comments): YES
All required baffles in place(N/A=No baffles required): YES
Effluent Filter Cleaned(N/A=Not Present): N/A
Effluent fitter/screen needed cleaning on arrival N/A
Compartment 1 Scum accumulation(Inches,if other specify): 0
Compartment 1 Sludge accumulation(Inches,if other specify): 5
Compartment 2 Scum accumulation(Inches,if other specify): 0
Compartment 2 Sludge accumulation(Inches,if other specify): 4
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper:
TANK:Septic Tank-2 Compartment 235 KALA HEIGHTS
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits(if NO explain in comments): YES
All required baffles in place(N/A=No baffles required): YES
Effluent Filter Cleaned(N/A=Not Present): N/A
Effluent filter/screen needed cleaning on arrival N/A
Compartment 1 Scum accumulation(Inches,it other specify): 2
Compartment 1 Sludge accumulation(Inches,if other specify): 4
Compartment 2 Scum accumulation(Inches,if other specify): 0
Compartment 2 Sludge accumulation(Inches,if other specify): 2
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper:
TANK:Septic Tank-2 Compartment 201 KALA HEIGHTS
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits(if NO explain in comments): YES
All required baffles in place(N/A=No baffles required): YES
Effluent Fitter Cleaned(N/A=Not Present): N/A
Effluent filter/screen needed cleaning on arrival N/A
Compartment 1 Scum accumulation(Inches,if other specify): 0
Compartment 1 Sludge accumulation(Inches,if other specify): B
Compartment 2 Scum accumulation(Inches,if other specify): 0
Compartment 2 Sludge accumulation(Inches,if other specify): 2
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper.
TANK:Septic Tank-2 Compartment 193 KALA HEIGHTS
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits(if NO explain in comments): YES
All required baffles in place(N/A=No baffles required): YES
Effluent Fitter Cleaned(WA=Not Present): N/A
Effluent filter/screen needed cleaning on arrival N/A
Compartment 1 Scum accumulation(Inches,if other specify): 2
Compartment 1 Sludge accumulation(Inches,if other specify): 6
Compartment 2 Scum accumulation(Inches,if other specify): 0
Compartment 2 Sludge accumulation(Inches,if other specify): 2
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper:
TANK:Pump Tank 1000 gallon
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Compartment 1 Scum accumulation(Inches,if other specify): 0 _
Pump vault screen needed cleaning on arrival N/A
Compartment 1 Sludge accumulation(Inches,if other specify): 0
Pump Vault Filter cleaned(N/A=not present): N/A
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper
This repot Indicates=Will characteristics of the male sewage system at the time of visa In m way is Otis report a guarantee of operation or ruler performance.
ReportlD:401615 View inspection reports online at vwm.onlnenne.com Page 2 of 3
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Controls functioning: YES
Dose setting different than original(If'YES,detal in comments) N/A
Dose setting adjusted to meet as-built/record drawing specifications(by the O&M Specialist) N/A
Tested gallons per minute flow: 138
Ili
This nspatu,dcstes caftan d,eremwieti:a dee angle sewage syeMm et we time dgiet M mwayee this rem'I a gueanree of wend=or future pesformence
ReportlD:401616 View inspection reports online at www.oninerme.com Page 3 of 3
• D •
BUILDING PERMIT APPLICATION B Review Type:
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00233 Received Date: 7/9/2015
SITE ADDRESS: 263 KALA HEIGHTS DR
OWNER: BARBARA DAWSON PHONE: 360-316-9472
ROBERT J LONGMIRE
263 KALA HEIGHTS DR
PORT TOWNSEND WA 98368-9506 9658 - KALA HEIGHTS PUD A&B
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 965800010 Section: 27 Township: 30 N Range: 11/1
CONTRACTOR: INTEGRITY HOMES & REMODELING PHONE: (360) 316-9472
124 SWANSON AVE
PORT TOWNSEND WA 98368
Contractor's License INTEGHR953PD Expires 10/4/2015
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NEW DECK- ON EXISITNG HOME
SEP92-00378
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 6,586.00 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: 332
BANK HEIGHT:
SEWAGE DISPOSAL: CMY
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $124.00 SRE 07/09/15 156234
Plan Check $80.60 SRE 07/09/15 156234
State Building Code $4.50 SRE 07/09/15 156234
Total: $209.10
IVidnnInr41r1n4,1fnrm<1F RI fl Ann RIrV rnl 7/0/9MF
• •
�¢gON co DEPARTMENT OF COMMUNITY DEVELOPMENT
�� 621 Sheridan Street,Pon-Townsend,«A 98368
aC Tel:360.379.4450 Fax:360.379.445 r
Web:awu.co.ieffm-sou,titaus/co�ar.�. t'r-c.'-e< ie�ct. D el
E-mail dcclkco.jefferson.wams
'1`rAIN��0 / On „ a
l/
PERMIT APPLICATION ✓ (I/' Lai/ ■
8
20 I)
Steps in the Permit Process: DE�Ff\.. l�
-Review application checklist to ensure all information is completed prior to submitting app TOF.t, UN OpN�
-Make sure septic has been applied for and water availability has been proven. Df'loplyi T
-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: qG,5 YO Q C.) I 0 / // /� / /1
Site Address and/or Directions to Property: ZG3 Kct t q tic 4 is &qv&-- (k41 Po r�t9 a
PGf• wrl S.t.&c ( WA 31.3 6 3' z/
Access(name of street(s)) from which access will be gained:
Present use of property: �'; rt R
Description of Work(include proposed uses): Add deck
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO tie"-
If not served by sewer identified above,identify type of septic system below:
Type of,11wage System Serving Property:
_ Septic Septic Permit#: Se 4 ' 2 '', ^ O0 7 a
VCommunity Septic Name of System: L(tt/• . -. . to - 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: i0/4 / 201 4( Attach last report to application
Describe or attach any drainfield easements,covenants or notices on title,which may impact the property:
• •
The authorized agent/representative is the peimary contact for all project-related questions and correspondence- The County will
mail/e-mail requests and information about the ipphcation to the atthorized agent/rtpresentatree 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 their mailbox accepts Conan
email t' bloc-Led e.,County email is not blo d or sent to"tusk ma3°
3_
IApplkant/Property Owner Information
i Property Owner fI y� 1
i Name: GAr4)orr+ Ont,,(�cs.A. rf- 11, LIlir T. L0.13 4,4.-?.._
Address: 2L.f kctfc ill c3 -S Or f fr1 Tnirnc,rivigi btjA rt1 1b `d'
Phone#: 34 zr° 94.4L/.. ozo 1 f-marl Address: be to ) 1-ol Aiwa.. •tlPq
— Please contact • • ..rized Agent/Represennative with project info.(setect'only one). JJ _
Property Owner Signature: �•,�i.a . ` , Date:A/Of z lS
Note: For projects with multiple owners,attach a , w sheet with ea owner(st iidermatian and signatures.
Applicant Authorized Agent/Representative(sfm ersu m,
n .nei
Name: Oc.-a(ti clav-I-64n
Address: !It-4 Swc„s--•, Put- . P rF T4` 1.Ase , WA ri$ 36 r
Phoned: 34e • 31V •-C /72_ E-mail Address: ,,iii r II,4 ,,sie.yr)CA/I-is, c,cj
I Professional: Is this an Authorized Agent/Representative for this project? NO YES
j Engineer Architect Surveyor 7C.-Contractor Consultant
Name: Scrk k_ a-5 4beL"1--
Address-.
Phone#: E-mail Address:
I Professional Is this an Authorized Agent/Representative for this project? NO YES
Engineer _ Architect Surveyor Contractor Consultant
i Name:
Address:
Phone#: £-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:
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant
Name:
Address:
Phone a: E-mail Address:
T. 1
Attach additional pages if necessary
i 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:Ce 14gin lftu3.I1� Print Name:u] 7£C� +J W►lf� Date: ,{s j3(j/ZOS jI
• •
4e ON �o DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,PortTottastnd WA 9 36S
Tel 360.379.4-450 Fax:36€7.379.4451 r
tiWeb:wu�w.co.jeff erson.tsa.uslcomrunitc�development D
E-mail:dcd(dco.jefferson.Ewans r,� 7+
4:--4/ � ;I i ; JUL - 8 2015 !id)
N SUPPLEMENTAL APPLICATION u I
RESIDENTIAL OR COMMERCIAL BLDG PE I_ �- 11:7010\.11
J
A#PT 0f eOfviPrtl; 111:!Evt ,iNr^,Fni
For Department Use Only Receipt#_ 'Rate _
Related Application#s: Payment#:
Site Information
Owner Name: Oafbotrot QttuJ 3o.-t Assessor Tax Parcel#: q(o g 8 oo c ( 0
P.bbar+ cl r Loust
Type of Building
New Replacement Relocated
Addition Repair Demolition s
tt j •A separate permit is required
Select One: 1 n ctd de.cL 4 r c n f of honaL a+ -PIczo
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors #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 t-'
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement-unfinished
Basement-finished space or habitable
Detached Garage-heated/unheated
Attached Garage-heated/unheated 2q
Garage 2nd fl-unfinished storage
Garage 2nd fl-finished space or habitable
Carport-2 walls or less
Deck-uncovered q0 33 Q (PS9,P-
Covered porch t ( 0
Other(shed,barn, pole bldg,etc.)
-Estimated Cost of Project (Required): $ a,000.0-6
• •
List existin: buildings on property(i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All Existing Buildings on Property Use
R
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:
By signing this application form,the owner/agent attests that the information provided herein, and in any attachments,is true and
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent
with respect tp this application pac et ma ult in making any issued permit null and void.
n �l /
Signature: ,i�- _ ./0 Print Name: Y��tet��C 4+r/'7�''l<(Jr' Date: ? 71, / s
Eor`D„epartment X)se '
Building Permit Fees
Building Base 114 'U
Plan Check Review (J�- 1Lr°
Land Use Review $234.00
Septic Review $129.00
Potable Water "$-1.30780 —
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Total Fees Le
Receipt# Date: Cash/Check/CC:
Si Mme t 1 JFR 2
rce--30N`co�� JEFFERSON COUNTY ► InI C CCU �� Q �I/ i i�
44
rz, ,.: ,a DEPARTMENT OF COMMUNITY DEVELOPMENT j !` ,Ii �'
\ 621 Sheridan Street • Port Townsend • Washington 98368 in ! j I! !
9 JUL - 82015 i ,i
�S, cO 360/379-4450 • 360/379-4451 Fax U �� �J
$INS http://www.co.jefferson.wa.us/commdevelopment/ j
I JEFFERSON COUNTY
.____PET.OF COMMUNITY!E1/ELOP"
Stormwater Calculation Worksheet
MLA# PROJECT/APPLICANT NAME: Dam.)S O AIW vkJ Mi rt__ arts-k. rydA.) d
— — Oo,n.(a_Lkar I4 e — O BA -1- rz }4 N eJ
DETERMINING STORMWATER MANAGEMENT REQUIREMENTS: This stormwater calculation worksheet should be cb'mple ed 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., SITE1
Size of parcel .2h7 g acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet (2 , I I_S' 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 20 sq/ft native vegetation to lawn or landscaped areas?
Draintleld,septic tank, etc. sq/ft Circle: Yes No
Well, utilities, etc. sq/ft Does the project convert 2 1/z 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 4 75 Fill /- (culyd)
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• • . .
SON � E 0 IH, � V S
�/� s J c. JEFFERSON COUNTY D/ !
-\'-',. _ DEPARTMENT OF COMMUNITY DEVELOPMENT I JUL — 8 2015
`,S 621 Sheridan Street • Port Townsend • Washington 98368 I
O 360/379-4450 • 360/379-4451 Fax • JEFFERSON CouNTY
1,_ KO http:/Iwww.co.jefferson.wa.us/commdevelopment/ DEPT.OF COMMUNITY DEVFtOP":1FN?
Stormwater Calculation Worksheet (� / ((�� i '
MIA# PROJECT/APPLICANT NAME: Dal-u-Se>vk/L�1h4Mit•�. QSLG� A l-4a�.
Dow,.IZcin(((ct -1-1-or. - 0[3A Tn-filt4.6 Rom-eJ
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 .217$ acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet U U. , 1 2..S 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 20 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'h 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 4 75 Fill /f (cu/yd)
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• • , ,
•
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 CALULATIONS– IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) sq/ft Structures(all roof area) 2, Y38" 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 L1(6 sq/ft
Other ��yy sq/ft Other sq/ft
Total New _sq/ft Total Existing 31 25-1 sq/ft
TOTAL NEW+TOTAL EXISTING" l k 2 s –( sq/ft
"This amount will be used BY STAFF 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: •26 g
Does the site have 35%or more of existing impervious surface? Circle: Yes 0
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 Slormwater 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.
11111L 4 _ 7h`7/"S
(LANDOWNER OR AUTHOR ED REPRES ATIV •IGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater rain wr rkchnal Fcv 4_4.91!:_OF V 4rcnn,n
• 7/31103
DEPARTMENT OF COMMUNITY DEVELOPMENT
ADMINISTRATIVE
WATER CONSERVATION MEASURES LIST
To Promote Aquifer Recharge
and Prevent Seawater Intrusion
1. Roof and other intercepted precipitation shall be routed to on-site detention ponds
and/or other approved means and allowed to be released to the soil slowly.
2. Water collected ardens.
Unless atchments water has ebeen treated to meet drinking
lawns and g
water standards,there shall be no cross connections allowed between the potable
supply and impounded water.
3. Ground water withdrawn from each property should not exceed a rate of three (3)
gallons per minute.
4. Install water-conserving fixtures such as low flow toilets,faucets and shower
restrictors and other water saving plumbing fixtures.
5. Landscaping should include xeriscaping and native vegetation with minimal amounts
of irrigation.
6. Use drip irrigation, soaker hose systems and root irrigation.
7. Use water basin techniques
less water lants, shrubs and trees.
8. Routinely water deeply frequently_
9. Weed control is an important part of water conservation.
10.For your landscaping select drought tolerant plants, shrubs and trees stay away from
heavy water consumers.
11. Limit the amount of irrigated lawn.
12.Mulch your garden as well as isolated plants,trees and shrubs.
13.Use shade and windbreaks to assist in water conservation.
14.Use low flow water closets,showerheads and water conserving dish and clothes
washers.
15.Use rainwater catchment systems that corral rainwater from manmade surfaces and
into storage.
16. Install water-conserving e a day or should be pumped d toilets and
all exemlptnwel plumbing fixtures.
17. Only 400 gallons p Y or
Seawater Intrusion Protection Zones(SIPZ).
18.Water softeners that contribute salt to groundwater through infiltration should not be
used in SIPZ.
19. Hose bibs (outdoor spigots) for outdoor water use should not be used in SIPZ.
lend]
PLEASE NOTDE- LETIONS MADE AT
NY TIME. USE HAVE
CURRENT LS E ADDITIONS