HomeMy WebLinkAboutBLD2015-00202 - 01 PERMIT APPLICATION • (5(--0\ s - 202
4� N co
DEPARTMENT OF COMMUNITY DEVELOPMENT
4, ��� 621 Sheridan Street,Port Townsend,WA 9S368
Cz4Tel:: 9.4130 Fax:360.37
Web:wvv-w.co.Jefferson.wa.ui/eommuu[jdevelopmcnt E o I- uv E �\
E-mail:dcd@co.iefferson.wa.us ,D r_.
1 1
16NINO'C' I fl I JUN 1 7 2015
PERMIT APPLICATION � LI I
�
Steps in the Permit Process: JEFFERSONOMMNCOUNTY
VE
_ DEPT.OF COMMUNITY DEVELOPMENT
-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#5: MLA#
Site Information
Assessor Tax Parcel Number: cd ) 2 3 V ) S
Site Address and/or Directions to Property: + i
5 2 1? 0-?1,30b n J -- r ror�t\n q (r) ,o is R o)
Access(na of street(s)) from which access will be gained: I
Present use of property: Vo 't hh d -- SI .-2., 6 f 4.e1-wItrr tura, ¶ 6 —vrN LdI
Description of ork include proposed uses): J
17� 2clie.j l3 43Q y gp1-Q 7e — n t. al-'e --, uriA a]1��
me,-fr�� b ►yl IJ l►-1 0v� ! r 11 d- Y- ¢. '�e_ --covnolz, fia:� J 5 [.b
Wastewater-Sewage Disposal
s_.
._._)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: 1
�r Septic Septic Permit#: c ( 09 q 7 / oz
Community Septic Name of System: f)' he. --So k IA sora Case#:
Are other residences connected to the septic system? A/(7
Additions or repairs to sewage system: AL34 tI e
Is it a complete or partial system installation: Complete\J Partial _ _
Has a reserve drainfield been designated? l Yes v No
Date of Last Operations& Maintenance check: / 22,1 2 O)S _ _
Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title,which may impact the property:
1 ,
The authorized agent/representative is the primary contact for all project-related•tions 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 their mailbox accepts County
email(i.e.,County email is not blocked or sent to"junk mail").
Applicant/Property Owner Information
Property Ow
Name: f 2Y1 1. oL >< S 6ku ` _ '
Address: 50( s c ry / vi I t 0.,)1/7W 9 c 3 I?
Phone#: 36 — if 2_ • 3 E-mail Addrlss:
— _ Please cont..t Autho •• A:ent/Representative with project info. (select only on . ty
Property Owner Signature: /7 � . Date: J 15
Note: For projects with multiple owners,attach a sep•ire sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative(if other than owner)
Name: tt )< S• ' t VAI Z is 0 I Y Ifin. ! L�
c�t� d2 Ya {�isn
Address: p. U . d3 ay, 21? , Pa 1� I 'aC le c l< r Ijl/ 1v 9 E 3t 37
Phone#: r7 3 s.6 -- G0 s E-mail Address: f S H gyp+•t AA yeeM, COM
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:
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 they will be as uming the responsibility of the General Contractor for the proposed project.
Signature: _4 Print Name: Date:
oN co DEPARTT OF COMMUNITY DEVE. ►
� 6 1 Sheridan Street,Port Townsend,nsend,WA 98.68 E O V E
W Tel:360.379.4450 I Fax:360.379.4451
Web: vww.co.iefterson.wa.us/communitvdevelopmenr
E-mail:dcd(it co.iefferson.wa.us i / 2015
��Skr NG' C) SUPPLEMENTAL APPLICATION -
1EFEERSOPJ COUNTY
RESIDENTIAL OR COMMERCIAL BLDG P RMI-ToFCOMMUNITY DEVELOPMENT
For Department Use Only Receipt#: Date:
Related Application#s: Payment#:
Site Information
Owner Name: 0j .Qh (), o l n s e r Assessor Tax Parcel#: 2)3 a )S'
Type of Building
New V Replacement Relocated
Addition Repair Demolition
*A separate permit is required
Select One:
Single Family Residence Modular Other6-ar.a list
O c a./
Proposed Building/Project
Number of floors ) # new bedrooms ,i- /M existing total bed
# new bathroomsw // existing total bath
Heat Source
Select all that apply: ( h eA,
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 heate unheate " 0 9 6 U
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): $ 7 .250 $
I
List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All Existing Buildings on Property Use
Vr5 Q., q) Pou 7Q 1iJ1 VA^C6 Cover
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
corr - • •e best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent
wi, respect o •" -=• "-:tion packet may result in making an d permit d void.
5-1 iM
Si: s.at e. Abide Print Na 57 c(( , �'►t�Y� Date:
For Department Use Only
Building Permit Fees
Building Base S . U(3
Plan Check Review lay S
Land Use Review $234.00
Septic Review -r�gg.gQ_ °°
Potable Water
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees 9 ! Z
Receipt # Date: Cash/Check/CC:
151e C`+�i (ph -T/1 ia9i83G -
r.
• N
ca' �1 ' M • 5/7/2015
Shod Excavating Inc. �—V
PO Box 179 350-385-0480
Port Hadlock, WA 98339
litrAk
PROPERTY INFORMAT•
Location:1521 DABOB fL 1 r
QUILCENE \\ V'I G
Tax ID:801213 ,1 ' l lUPi 1 7 CJl J
Mai]To: DIANE JOHNSON
1521 DABOB RD Use: t I
QUILCENE,WA (AO
PMENT
Owner:DIANE JOHNSON
DEPT Of COM10::::05: 04-00312��Nln DE
ON ID:SOlEMIO04-00312
Fold ,--11•1511r4J•:114i/1114AI:1 111„I4.YfAf-314„1I,F167-C.ig.1J;1-1:L•I Fold
Her. Here
Inspected:04/22/2015 - Inspection Type:ROUTINE - Correction Status:No corrections needed
Company: Certification-Level 2 Work Performed By: Submitted 04/28/2015 by:
Shold Excavating Inc. Martin Fugere Timothy Johnson
This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development.
COMMENTS&GENERAL INSPECTION NOTES
No Deficiencies Noted
GENERAL SITE&SYSTEM CONDITIONS
The General Site and System Conditions were: Fully Inspected
All Components accessible for maintenance,secure and in good condition: YES
Surfacing effluent from any 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 ._._...._ ..._...__.-_...._ .. .._..______. --- N/A _--
Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: NO
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? N/A
(If NO,describe in notes,NA=no deficiencies on last report):
OSS Components,structures and appurtenances located per as-built/record drawing(If NO,describe YES
in notes). If no as-built exists or changes made,state NO and provide record to Health Dept:
Alterations made to the OSS(valves adjusted,timer settings modifiedports installed,etc.)(If YES, NO
describe in notes):
The house/structure was vacant or used infrequently,assessment of the drainfield was not possible. NO _.
tu -- - -_
Is the SEP case in a finaledlcompleted status?(if NO explain in comments) YES
ONSITE SEWAGE SYSTEM INSPECTION DETAIL
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): YES
Effluent filter/screen needed cleaning on arrival NO
Compartment 1 Scum accumulation(Inches,if other specify): 2”
Compartment 1 Sludge accumulation(Inches,if other specify): 3•'
Compartment 2 Scum accumulation(Inches,if other specify): 0"
Compartment 2 Sludge accumulation(Inches,if other specify): 1^
Pumping needed: NO
Approximate Gallons to be pumped(if needed)by Certified Pumper: o
ReportiD:435294 View inspection reports online at www.onlinerme.com Page 1 of 2
a istribution:D-Box
This component was: Fully Inspected
D-Box in good condition: YES
0-Box outlets set to allow equal effluent distribution: YES
a rainfield:Gravity
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Ponding present?If YES explain in comments: NO
This report indicates Certain characteristics tithe onsite sewage system at the tune or visit In no way is this report a guarantee of operation or future performance.
ReportiD:435294 View inspection reports online at www.onlinerme.com Page 2 of 2
•
I
/r��w��°N coG� JEFFERSON COUNTY
ai .`, r7 DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368
O 360/379-4450 • 360/379-4451 Fax n r C Lt [IV 1
1`,HINr'� http:!lwww.co.jefferson.wa.us/commdevelopmenU I �� r�
1 J_/ i
. JUN 1 7 2015 1
Stormwater Calculation Worksheet u, 1
I JEFFERSO`I LOUNTY
MLA# PROJECT/APPLICANT NAME: I��-OF COMMUNITY DEVELOPMENT
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.
p ? PARCEL SIZE (I.E.,SITE1
Size of parcel f d 73 7 acres C� c�An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 2 3 � t t 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 9 /6 sq/ft native vegetation to lawn or landscaped areas?
Drainfield, septic tank, etc. .A f"/ sq/ft Circle: Yes No
Well, utilities, etc. J° ill sq/ft Does the project convert 2'/2 acres or more of
Q native vegetation to pasture?
Driveway, parking,roads, etc. ` 0 sq/ft
h Circle: Yes No
Lawn, landscaping, etc. 7( 7`' sq/ft
0 Other compacted surface, etc I 0 _ sq/ftIndicate Total Volumes of Proposed:
Total Land Disturbance 1. G. Li' 0 sq/ft Cut 5 Fill 1 Cl ( C (cu/yd)
[over]
stormwater colt worksheet Rev 9-9-2010-REV 9192010 1
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 f� l EXISTING 1 p�
L!
Structures (all roof area) / v sq/ft Structures (all roof area) 3 0 sq/ft
Sidewalks sq/ft Sidewalks sq/ft
Patios N / )< sq/ft Patios sq/ft
Solid Decks /v / 7'1' sq/ft Solid Decks sq/ft
(without infiltration below) CZ (without infiltration below)
Driveway, parking, roads, etc 1 O 0 sq/ft Driveway, parking, roads, etc `T � sq/ft
Other sq/ft Other sq/ft
Total New 3 3 Op sq/ft Total Existing 5 SD 0 sgift
el cot
TOTAL NEW+TOTAL EXISTING* M D `10 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:'�� %
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 Stormwater Management Manual.
APPLICANT SIGNATURE
By si•ning the Stormwater Calculation Worksheet, I as the applicant/owner attest that the information provided herein is true and
.rrec • the best of my knowledge. I also certify that this application is being made with the gull knowledge and consent of all
owners o th= = - -• pro.-rty.
r2 r 5
f DO ER OR AUTHORIZED''EPRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater calc worksheet Rev 9-9-2010-REa 9/9/2010 2
Parcel Details • Page 1 of 2
•
atili lli7
°1 - ie erson County
d. , r -A
...
Home Caunty Info Departments �� Search 1
Parcel Number: 801213015 SEARCH
Parcel Number: 801213015 Printer Friendly
Owner Mailing Address:
DIANE JOHNSON
1521 DABOB RD
QUILCENE WA98376-9725
Site Address:
1521 DABOB RD
QUILCENE 98376
Section: 21 School District: Chimacum (49)
Qtr Section: SW1/4 Fire Dist: Quilcene (2)
Township: 28N Tax Status: Taxable
Range: 1W Tax Code: 0221
Planning area: South Toandos Peninsula,Coyle Area (9)
Sewer: Drainage:
Bank: View 1:
View 2: Zoning 1:
Zoning 2: Zoning 3:
Sub Division:
Assessor's Land Use Code_ 1100 - Residential - Single Unit
Property Description:
S21 T28 R1W N1/2 NW SW (LYING E/CO RD) LESS TAX 19, ENLG BY TAX 22 BND
TGTH THRU BLA#104374
Tax,A/V, Sales. Photos, and
Permit Data Bldg Data Ma I Parcel 'rats&Surve s
Septic Monitoring_Info
- !
Jefferson County HOME I COUNTY INFO I DEPARTMENTS I SEARCH
Best viewed with Microsoft Internet Explorer 6.0 or later
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http://www.co.jefferson.wa.us/assessors/parcel/parceldetail.asp?value=801213015 6/17/2015
OLYMPIC STEEL LLC Page 1 of 2
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OLYMPIC STEEL LLC
Owner or tradesperson 271 CUB RD
PORT TOWNSEND.WA 98368-9674
Principals 360-385-6059
SHIPMAN,RICHARD JEFFERSON County
MARTIN,PARTNER/MEMBER
Doing business as
OLYMPIC STEEL LLC
WA UBI No. Business type
603 002 624 Limited Liability Company
License
Verify the contractor's active registration/license/certification(depending on trade)and any past violations.
Construction Contractor Active.
Meets current requirements.
License specialties
GENERAL
License no.
OLYMPSL900NZ
Effective—expiration
08/0912010—08/09/2016
Bond
Lexon Ins Co $12,000.00
Bond account no.
9809955
Received by L&I Effective date
09/01/2011 09/10/2011
Expiration date
Until Canceled
Bond history
Insurance
American States Insurance Co $1,000,000.00
Policy no.
01C116827270
Received by L&I Effective date
03/10/2015 03/22/2015
Expiration date
03/22/2016
Insurance history
Savings
N..savings accounts during the previous 6 year period.
Lawsuits against the bond or savings
No lawsuits against the bond or savings accounts during the previous 6 year period.
L&I Tax debts
No L&I tax debts are recorded for this contractor license during the previous 6 year period,but some debts
may be recorded by other agencies.
License Violations
https://secure.lni.wa.gov/verify/Detail.aspx?UBI=603002624&LIC=OLYMPSL900NZ&SAW= 6/17/2015
OLYMPIC STEEL LLC Page 2 of 2
No license violations during the previou ar period.
Workers' comp
Do you know if the business has employees?If so,verify the business is up-to-date on workers'comp premiums.
L&I Account ID Account is current.
968,993-01
Doing business as
OLYMPIC STEEL LLC
Estimated workers reported
Quarter 1 of Year 2015"Less than 1 Workers"
L&I account representative
T3/DEBRA MODER(360)902-5598-Email:MORE235@Ini.wa.gov
Workplace safety and health
No inspections during the previous 6 year period.
m Washington State Dept.of Labor&Industries.Use of this site is subject to the laws of the state of Washington.
https://secure.lni.wa.gov/verify/Detail.aspx?UBI=603002624&LIC=OLYMPSL900NZ&SAW= 6/17/2015
BLD15-00202
*BUILDING PERMITAPPLICION Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00202 Received Date: 6/17/2015
SITE ADDRESS: 1521 DABOB RD
QUILCENE, 98376
OWNER: DIANE JOHNSON PHONE: 360-532-4283
1521 DABOB RD
QUILCENE WA 98376-9725
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801213015 Section: 21 Township: 28 N Range: 1V1
CONTRACTOR: OLYMPIC STEEL PHONE: (360)385-6059
DICK SHIPMAN
271 CUB RD
PORT TOWNSEND WA 98368
Contractor's License OLYMPSL900NZ Expires 8/9/2016
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOri NEW DETACHED 3 BAY GARAGE- NO PLUMBING- NO HEAT
SEP04-00312
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 27,250.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY:
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: SHORELINE:
CONST TYPE: GARAGE: 960 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $355.00 SRE 06/17/15 156149
Plan Check $230.75 SRE 06/17/15 156149
State Building Code $4.50 SRE 06/17/15 156149
Total: $590.25
llfiricmrlr\rInf,\fnrn,c\I= RI Il Ann Rlri mf R/17/9lNR
• •
'`'�sON co DEPARTMENT OF COMMUNITY DEVELOPMENT
4 �- 621 Sheridan Street,Port Townsend,send,\ A 98368
l y „C Tel:360379.4430 I Fax:360.379.4351 �(f
Web. m
WWW. o.efferson.wa.us immwvtvdevelo u 5 0 �ti JJ
E-mail:dcdeco.iefferson.wa.us
�SIfI N G \�` I10 n0 2015
n �U
PERMIT APPLICATION .1I
Steps in the Permit Process: U }EFFERSON COUPiN
SPT.OF Fl UEVELOPNiE�
-Review application checklist to ensure all information is completed prior to submitt ..: . . ion.
-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: �j V ) 2 I 3 l_ ) ) S
Site Address and/or Directions to Property:
i 5 .2- i D?b'b If? ci — r r,ory' n 9' c9 �b.b Rtj
Access(naof street(s)) from which access will be gained:
dnah0,b p of
Present use of property: V.2c ah-t- la 1 d "-- -£
5I- , b f ,+at-.,r,Gy- (rYa C�,® _ tbiii^n /A-)Description of ork(include proposed uses): J
� 21 , Jr ` 3 e& y r a ;'
e — n 8 � ��-t U.i h e;i-�c)
MP"fr& (/ (
L4, ,) f) YL 0 !'S i^ ar45. -co vnJa1"t:,:4/ 51.. .17
Wastewater-Sewage Disposal
r_-
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: r ss�e11 )
_ �' Septic Septic Permit#: SE(p 09 -- 'j 1 az
Community Septic Name of System: 0)1 h t �o I,vt sok Case#:
Are other residences connected to the septic system? ,(�
Additions or repairs to sewage system: /V o i4 e
Is it a complete or partial system installation: Complete\ ► _ Partial _ _
Has a reserve drainfield been designated? Yes v No _ _
Date of Last Operations& Maintenance check: j ,) 22-1 2 0 2.5
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 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 their mailbox accepts County
email(ii.e.,Count-email is not blocked or sent to"junk mail").
Applicant/Property Owner Information
Property Ow 1
Name: j 2LI �� oIn 6
Address: 5 ( ��)2 f Q / cu -T \`
Y1, J / r
9 3
Phone#: 6 - ; — l� 2. E-mail Addrerss:
— _ Please cont.,t Autho ' -. A:ent/Representative with project info. (select only on . 1
Property Owner Signature: 9 ' /4- 11-20277,____-- Date: �� 1.5
Note: For projects with multiple owners,attach a sepaa e sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative(if other than owner)
Name: Dat k 5 r l�t,AM ��71` � a f 01 Y ac c<zo, I LLC
Address: p U ✓� Jac 2 ( 0'0 izt /- ,4 933 %1 (�
Phone#: 1 ., Q E-mail Address: fl cH 1P/lei 'Qf 31 yeah, Cowl
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: •
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 they will be as uming the responsibility of the General Contractor for the proposed project.
Signature: if„/ Print Name: Date:
co DEPAPMENT OF COMMUNITY DEVELOPMENT
6a 621 Sheridan Street,Port Townsend.WA 9836E l 0 E E
Tel.360.379.4450 Fat:3603-9.4451
”CWeb.www.co.iefterson.u-a.us'commurun-developmenr
E-mail:dcd(2'co.iefferson.ma.us
! JUN 172015
16WrN6C9 SUPPT.FMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG pER.A FER50N COUNTY
MEM
DEP . OMMUNTY DEVEIOP
For Department Use Only Receipt#: Date:
Related Application#s: Payment#:
Site Information/Th
Owner Name: 1 J y% 0 0 h Assessor Tax Parcel#: 2)3 0 ),C
Type of Building
New V Replacement Relocated
Addition Repair Demolition
*A separate permit is required
Select One:
Single Family Residence Modular Other6- i-Q list
Proposed Building/Project
Number of floors ) #new bedrooms Af-t4 existing total bed
#new bathroomsN lt4 existing total bath
Heat Source
Select all that apply: V k- QZ a
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 heatedunheate ) 9 6 0
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): $ 7 2 5.) $
•
List existing buildings on property (i.e.�se, garage, accessory dwelling unit, shed, barn, mobile home,other):
All Existing Buildings on Propertyy UVio V SC, s
‘,41h-r. s� vlrc CVv O-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 theywill be assuming the responsibility of the General Contractor for the proposed project.
(/
Signature: r- /be' ` Print Name: Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and
corr=- . •e best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent
wi• respect o .' -•• •-:tion packet may result in making an d permit n nd void.
1115
Si: at e. � /
Print Na C 1 ler g-V\ Date:
For Department Use Only
Building Permit Fees
Building Base
Plan Check Review
Land Use Review $234.00
Septic Review $80.00
Potable Water $109.00
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt# Date: Cash/Check/CC:
c tI 5/7/2015
eP
Shoid Excavating Inc.
PO Box 179 � Q
Port Hadlock, WA 98339
I,
�._
PROPERTY INFORMATI
'
0ti JUN 1 7 N15
Location:1521 DABOB RD ! ,
QUILCENE
Tax ID:801213015 EFFERSOid COUNDEVFIT
DPMEt�(
Man To: DIANE JOHNSON •
pEpT,oFICOMM' '
1521 DABOB RD Use:
QUILCENE,WA
Owner:DIANE JOHNSON
ON ID:SOM04-00312
rma r ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT F0F0la
Here Here
Inspected:04/22/2015 - Inspection Type:ROUTINE - Correction Status:No corrections needed
Company: Certification-Level 2 Work Performed By: Submitted 04/282015 by:
Shold Excavating Inc. Martin Fugere Timothy Johnson
This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development.
COMMENTS&GENERAL INSPECTION NOTES
No Deficiencies Noted
GENERAL SITE S.SYSTEM CONDITIONS
The General Site and System Conditions were: Fully Inspected
All Components accessible for maintenance,secure and in good condition: YES
Surfacing effluent from any 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 N/A
Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: NO
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? N/A
(If NO,describe in notes,NA=no deficiencies on last report):
•
OSS Components,structures and appurtenances located per as-built/record drawing(If NO,describe YES
in notes). If no as-built exists or changes made,state NO and provide record to Health Dept:
Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If YES, NO
describe in notes):
The house/structure was vacant or used infrequently,assessment of the drainfield 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
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): YES
Effluent filter/screen needed cleaning on arrival NO
Compartment 1 Sam accumulation(Inches,if other specify): 2"
Compartment 1 Sludge accumulation(Inches,if other specify): 3"
Compartment 2 Scum accumulation(Inches,if other specify): 0"
Compartment 2 Sludge accumulation(Inches,if other specify): 1"
Pumping needed: NO
• Approximate Gallons to be pumped(if needed)by Certified Pumper: 0 •
ReportlD:435294 View inspection reports online at www.onlinerme.com Page 1 of 2
•istribution:D-Box
This component was: _ sully Inspected
0-Box in good condition: YES
D-Box outlets set to allow equal effluent distribution: YES
'rain field:Gravity
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Ponding present?If YES explain in comments: NO
This report indicates certain characteristics of the onsite sewage system at the time of vise In no way is this report a guarantee of operation or future performance.
ReportiD:435294 View inspection reports online at www.onlinerme.com Page 2 of 2
• •
.,i, "'''" ca& JEFFERSON COUNTY ��
A DEPARTMENT OF COMMUNITY DEVELOPMENT
j� -„ 621 Sheridan Street • Port Townsend • Washington 98368 `y ' ,�� ��15 J U
.qs, ,c.0 360/379-4450 . 360/379-4451 Fax 1' J+
SING httpa/www.co.jefferson.wa.us/commdevelopment/ 11 I\!
JtFfERSOf L°016-1,_
u
Dj___,1•015 \ ---"M11N1�V O_._ `�T
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 9'.' 33 acres p oAn acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet Z 3 � t e / 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/.acres or more of
Construction site for structures , _ sq/ft native vegetation to lawn or landscaped areas?
Drainfield, septic tank, etc.. {1 ril sq/ft Circle: Yes No
J" /A
Well, utilities, etc. sq/ft Does the project convert 2'/2 acres or more of
ICI0
native vegetation to pasture?
Driveway, parking,roads, etc. ` _ -' . sq/ft
/�} Circle: Yes No
/
Lawn, landscaping, etc. Ai ` 'r sq/ft
Other compacted surface, etL 7 0 0 sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance 1. .6. O sq/ft Cut 0 Fill J g( ] (cu/yd)
[over]
stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 1
• •
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 A T
Structures (all roof area) sq/ft Structures(all roof area) 1 3 0 V sq/ft
f�
Sidewalks /" /74Isq/ft Sidewalks --� sq/ft
N
Patios /N sq/ft Patios sq/ft
Solid Decks N / 7lr sq/ft Solid Decks –s sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking, roads, etc O 0 sq/ft Driveway, parking, roads, etc —I)�
- 0O sq/ft
Other2 / sq/ft Other sq/ft
3 V
Total New 3 0 sq/ft Total Existing C SO O sq/ft
TOTAL NEW+TOTAL EXISTING* b 0 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 I71
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage'r 3 J
Does the site have 35%or more of existing impervious surface? Circle: Yes 110
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. DOD 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 StonnwaterManagement Manual.
APPLICANT SIGNATURE
By si.ning the Stormwater Calculation Worksheet, I as the applicant/owner attest that the information provided herein is true and
.rrec • the best of my knowledge. I also certify that this application is being made with the ull knowledge and consent of all
owners o th= = - -. pro.••rty.
• 5 121 , 5
• DO ER OR AUTHORIZED'E PRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater ca'c worksheet Rev 9-9-2010-REV 9/9/2010
• BUILDING PERMIT APPLIcfION BLD15-00202
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00202 Received Date: 6/17/2015
SITE ADDRESS: 1521 DABOB RD
QUILCENE, 98376
OWNER: DIANE JOHNSON PHONE: 360-532-4283
1521 DABOB RD
QUILCENE WA 98376-9725
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801213015 Section: 21 Township: 28 N Range: 1V1
CONTRACTOR: OLYMPIC STEEL PHONE: (360)385-6059
DICK SHIPMAN
271 CUB RD
PORT TOWNSEND WA 98368
Contractor's License OLYMPSL900NZ Expires 8/9/2016
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI NEW DETACHED 3 BAY GARAGE- NO PLUMBING- NO HEAT
SEP04-00312
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 27,250.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: SHORELINE:
CONST TYPE: GARAGE: 960 SETBACK:
CK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $355.00 SRE 06/17/15 156149 APPROVED
Plan Check $230.75 SRE 06/17/15 156149
State Building Code $4.50 SRE 06/17/15 156149 JUN 2 4 2015
Total: $590.25
Jefferson County DCD
11firlomorIr\rinf,lfnrme\F RI rl Ann Rid rnf R/17/7M6
ILDING PERMIT APPLICATIM BLD15-00202
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00202 Received Date: 6/17/2015
SITE ADDRESS: 1521 DABOB RD
QUILCENE, 98376
OWNER: DIANE JOHNSON PHONE: 360-532-4283
1521 DABOB RD
QUILCENE WA 98376-9725
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801213015 Section: 21 Township: 28 N Range: 1V\
CONTRACTOR: OLYMPIC STEEL PHONE: (360)385-6059
DICK SHIPMAN
271 CUB RD
PORT TOWNSEND WA 98368
Contractor's License OLYMPSL900NZ Expires 8/9/2016
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOIf NEW DETACHED 3 BAY GARAGE- NO PLUMBING- NO HEAT
SEP04-00312
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 27,250.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: 960 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $355.00 SRE 06/17/15 156149
Plan Check $230.75 SRE 06/17/15 156149
State Building Code $4.50 SRE 06/17/15 156149
Total: $590.25
11firion,orL\,Vafv\fnrrnc\G RI rl Ann RH mf R/17/7(1l'