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HomeMy WebLinkAboutBLD2015-00195 - 01 PERMIT APPLICATION atUILDING PERMIT APPLICASN BRLD1e 00195 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00195 Received Date: 6/9/2015 SITE ADDRESS: 5411 SR 20 PORT TOWNSEND, 98368 OWNER: MICHAEL B BAIR PHONE: 425-788-5831 ELAINE S BAIR 5411 STATE ROUTE 20 PORT TOWNSEND WA 98368 SUBDIVISION: Block: Lot: T 39+ PARCEL NUMBER: 901051001 Section: 5 Township: 29 N Range: 1V1 CONTRACTOR: HALEYCO PHONE: 253-884-2130 17220 S VAUGHN RD KPN VAUGHN WA 98394 Contractor's License HALEY**953DP Expires 3/17/2017 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW 8X8 SPA POOL SEP11-00031 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 55,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: 64 CONST TYPE: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $622.00 SRE 06/09/15 156141 APPROVED Plan Check $404.30 SRE 06/09/15 156141 State Building Code $4.50 SRE 06/09/15 156141 JUL -9 2015 Total: $1,030.80 Jefferson County DCD 11firlcmarblrlcfelfnre1lr RI 11 Ann PIri r■f R/O/9M4 HALEYCO • Page 1 of 2 • Home Inicio en Espanol Contact Search L&I St ARCH A-Z Index Help My Secure IFd Safety Claims&Insurance Workplace Rights Trades&Licensing 0 Washington State Department of Labor & Industries HALEYCO Owner or tradesperson CIO MASBRUCH TIMOTHY A 17220 S VAUGHN RD KPN Principals VAUGHN.WA 98394-9705 MASBRUCH,TIM,OWNER 253-884-2130 Doing business as PIERCE County HALEYCO WA UBI No. Business type 601 086 987 Individual Governing persons COLLEEN M MASBRUCH TIMOTHY A MASBRUCH; License Verify the contractors active registration/license/certification(depending on trade)and any past violations. Construction Contractor Active. Meets current requirements. License specialties GENERAL License no. HALEY**953DP Effective—expiration 03/17/2005—03/28/2017 Bond ............ Wesco Insurance Co $12,000.00 Bond account no. 46WB017786 Received by L&I Effective date 02/26/2013 03/01/2013 Expiration date Until Canceled DEVELOPERS SURETY&INDEM CO $12,000.00 Bond account no. 745763C Received by L&l Effective date 03/0112007 03/01/2007 Expiration date Until Canceled Bond history Insurance Ohlo Cas Ins Co $1,000,000.00 Policy no. BL053598867 https://secure.lni.wa.gov/verify/Detail.aspx?UBI=601086987&LIC=HALEY**953DP&SAW= 6/9/2015 • HALEYCO • Page 2 of 2 Received by L&I • Effective date 02/02/2015 03/02/2014 Expiration date 03/02/2016 Insurance history Savings No 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 .......... No license violations during the previous 6 year period. • Workers' comp Do you know if the business has employees?If so,verify the business is up-to-date on workers'comp premiums. L&I Account ID Account is current. 579,868-00 Doing business as HALEY CO Estimated workers reported Quarter 1 of Year 2016"1 to 3 Workers" L&I account representative T4 I CARIE PICKETT(360)902-5592-Email:PICC235 @Ini.wa.gov Workplace safety and health No inspections during the previous 6 year period. ()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=601086987&LIC=HALEY**953DP&SAW= 6/9/2015 • • 03 0 N pe?� DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 0-‹ Tel:360.379.4450 I Fax:360.379.4451 Web:www.co.iefferson.wa.us/conununiiydevelopment E-mail:dcd @,co.iefferson.wa.us 41-N GeO PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application; it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# Site Information Assessor Tax Parcel Number: 901051001 Site Address and/or Directions to Property:5411 SN 20 Port townsend, WA. 98368 Access(name of street(s)) from which access will be gained: SR 20, Existing driveway Present use of property: Residential Description of Work (include pr osed uses): Install New Exercise Spa I t i 00-4 g `x g r 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#: cell-1"N j I — 000 Community Septic Name of System: Case#: Are other residences connected to the septic system? NO Additions or repairs to sewage system: NO Is it a complete or partial system installation: Complete V Partial Has a reserve drainfield been designated? Yes _� No Date of Last Operations& Maintenance check: 07/15/2014 Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: None The'authorized agent/representativillthe primary contact for all project-related Ikons 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 Owner: Name: Michael, Bair Address: 5411 Highway 20 Port Townsend Wa. 98368 Phone#: 360-379-4692 Email Address: mbbair11@gmail.com _ V_ Please con . fr. t ized nt/Representative with project info. (select only one).G Property Owner Signature: Date: 1 2 ( /S� Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(if other than owner) Name: Tim Masbruch DBA Haleyco Gen. Contractor#cchaley**953ddp Address: PO Box 441, Vaughn, Wa. 98394-0441 Phone#: 253-677-4474 E-mail Address: haleycompany @gmail.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 an. that they will be ass ing the responsibility of the General Contractor for the proposed project \ Tim Masbruch Signatur-. ll�► � Print Name: Date: .6,/q/-20/� • • r_ oN �,o DEPARTMENT OF COMMUNITY DEVELOPMENT tU G 621 Sheridan Street,Port Townsend,WA 98368 Tel 360.379.4450 Fax 360.379.4451 tim Web:www.co.Jefferson.wa.us/communitydevelopment . `� E-mail:dcd@a co.jefferson.wa.us �``sHrN6.- — SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt#: Date: Related Application#s: Payment#: Site Information Owner Name: (I/\( c_Lept ( 4t VI Assessor Tax Parcel#: `('6/0 /©0 Type of Building'' New )C Replacement Relocated Addition Repair Demolition * *A separate permit is required Select One: Pr,1/414-- s eA C?“)‹..(g" Single Family Residence Modular Other list Proposed Building/Project --" i1iW Number of floors (I.\ la, # 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.) S P A Co`f ri Estimated Cost of Project (Required): $ s6 $ Supplemental SIR I • • List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use 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 to this application packet may result in making any issued permit null and void. Signature: Print Name: Date: For Department Use Only Building Permit Fees l�� Building Base (Oc.l k '00 Plan Check Review 404 . 36 Land Use Review $234.00 Septic Review $129.00 Potable Water . + ' Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption 5y 0 Zoning Zoning Other New Address Total Fees Receipt # Date: Cash/Check/CC: • • �I.05°N % JEFFERSON COUNTY ,.z7 �.>, r✓r DEPARTMENT OF COMMUNITY DEVELOPMENT '' -`` - '� & ' '. 621 Sheridan Street • Port Townsend • Washington 98368 O 360/379-4450 • 360/379-4451 Fax �`SHING� http://www.co.jefferson.wa.us/commdevelopment/ Stormwater Calculation Worksheet MLA#F 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., SITEI Size of parcel r 1(9 acres (' `I An acre contains 43,560 square feet. Multiply the acreage by this figure. 111 V Size of parcel in square feet 2 q 7, '`dr 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 t O C sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank, etc. O sq/ft Circle: Yes Well, utilities,etc. O sq/ft Does the project convert 2'A acres or more of native vegetation to pasture? Driveway, parking, roads,etc. 0 sq/ft Circle: Yes No Lawn, landscaping, etc. d sq/ft Other compacted surface, etc. C1 sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance (L C sqlft Cut I Fill (cu/yd) [over] stormwater calc worksheet Rev 9-9-2010—REV 9/9/2010 • • 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) 1C to5 sq/ft Sidewalks sq/ft Sidewalks Vt A sq/ft Patios sq/ft Patios 1 r g sq/ft Solid Decks _ sq/ft Solid Decks '5%0 sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads,etc ,1 sq/ft Driveway, parking, roads, etc ((3(Cl sq/ft Other (06 sq/ft Other // sq/ft Total New (L O sq/ft Total Existing (4, `(C( sq/ft TOTAL NEW+TOTAL EXISTING' I "t to q sq/ft *This amount will be used BY STAFF 10 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: 62C'.ct I % Does the site have 35%or more of existing impervious surface? Circle: Yes 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 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. L4.0.111: /A■ /_` (LAND. 'OR A HOR' •EPRES'NTATIVE'IGNATURE) (DATE FOR OFFICE USE.ONLY SMALL_ MEDIUM LARGE REDEVELOPMENT__ Stormwater Site Plan: Yes No storrhwaler cats worksheet Rev 9-9-2010—REV 919/2010 • • • Shedd Excavating Inc. PO Box 179 360-385-0480 Port Hadlock, WA 98339 THIS REPORT HAS NOT YET BEEN LOCKED AND IS m PROPERTY INFORMATION SUBJECT TO FURTHER EDITING. Michael Bair Location:5411 HWY 20 Port Townsend Tax ID:901051001 Mai To: Michael Bair 5411 HWY 20 Use- Port Townsend,WA Owner:Michael Bair ON ID:SOM11-00031 F"d ONSITE SEWAGE SYSTEM INSPECTION REPORT Fold Pere Here Inspected:07/15/2014 - Inspection Type:ROUTINE - Correction Status:No corrections needed Company: Certification-Level 2 Work Performed By.' Shold Excavating Inc. Timothy Johnson 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). !IVES,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-buit/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,Manufacturer- Local Manufacturer-Concrete Manufacturer. Local Manufacturer Model:Concrete 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 Compartment 1 Scum accumulation(Inches,if other specify): 6" Effluent filter/screen needed cleaning on arrival NO Compartment 1 Sludge accumulation(Inches,if other specify): 2' Compartment 2 Scum accumulation(Inches,If other specify): o' Compartment 2 Sludge accumulation(Inches,if other specify): 2" This report indirabs certain cherectenstrrs of The onsee sewage system at the time OF,OF.In no way is Mrs report e guarantee of operation or Mare pertonaance. ReportlD:387090 View inspection reports online at www.onlinerme.com Page 1 of 2 Pumping needed: • NO Approximate Gallons to he pumped(if needed)by Certified Pumper: 0 APJK:Pump Tank,Manufacturer— Local Manufacturer-Concrete Manufacturer. Local Manufacturer Model:Concrete 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 NO Compartment 1 Sludge accumulation(Inches,if other specify): 2• Pumping needed: NO Pump Vault Filter cleaned(N/A=not present): YES Approximate Gallons to be pumped(if needed)by Certified Pumper. 0 'anel:Control-1 Purnp This component was: Fully Inspected Panel functioning(including alarm): YES Pump 1:on minutes(override in parentheses-if present): :55 Pump 1:off hours(override In parentheses-if present): 3:59:05 Pump 1:gallons per dose(override In parentheses-if present): S0 Pump 1:ETM hours(override in parentheses-if present): 10:14 Pump 1:Cycle Count(override in parentheses-if present): 679 amp:Effluent Pump This component was: __ Fully Inspected Component appears to be functioning as intended: YES Controls functioning: YES Dose setting different than original(If YES,detail in comments) NO Dose setting adjusted to meet as-buiRhecord drawing specifications(by the O&M Specialist) NO Tested gallons per minute flow: 63 Manufacturer.Infiltrator Systems,Inc. This component was: Fully Inspected Component appears to be functioning as intended: YES Lateral lines flushed: YES Average squirt height(if performed)(feet,if other specify): 42• Ponding present?If YES explain in comments: NO This wort indicates certain chsractenstics or the ensue sewage system at Me time of Nsd In no way is this report a guarantee of operation or More perfwmeece- ReporND:387090 View inspection reports online at www.onlinerme.com Page 2 of 2 • 'SHOLD EXCAVATING INC ' ' Invoice COTTON REDIMIX 1� v PO BOX 179 Date Invoice# PORT HADLOCK WA 98339 () 7/16/2014 29121 360-385-0480 FAX 360-379-6892 \11 Bill To MICHAEL BAIR 5411 HWY 20 PORT'TOWNSEND WA 98368 P.O. No. Terms Project #901 051 001 Net 10 days 5411 HWY 20 Date Quantity Description Rate Amount 7/15/2014 1 EVALUATION OF AN EXISTING ON SITE SEWAGE SYSTEM- 300.00 300.00T JEFFERSON COUNTY PUBLIC HEALTH FILING FEE 1 EES ONE TIME JEFFERSON COUNTY PUBLIC HEALTH DEPARTMENT 30.00 30.00T ONLINE SET UP I ONE TIME IN OFFICE FILE SET UP 30.00 30.00T SUBTOTAL 360.00 9%JEFF CO 1600 SALES TAX 9.00% 32.40 Total $392.40 1%SERVICE CHARGE WILL BE ASSESSED ON PAST DUE AMOUNTS OVER 30 DAYS MDap ILDING PERMIT APPLICATIN BRLD1e001195 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00195 Received Date: 6/9/2015 SITE ADDRESS: 5411 SR 20 PORT TOWNSEND, 98368 OWNER: MICHAEL B BAIR PHONE: 425-788-5831 ELAINE S BAIR 5411 STATE ROUTE 20 PORT TOWNSEND WA 98368 SUBDIVISION: Block: Lot: T 39+ PARCEL NUMBER: 901051001 Section: 5 Township: 29 N Range: 1V1 CONTRACTOR: HALEYCO PHONE: 253-884-2130 17220 S VAUGHN RD KPN VAUGHN WA 98394 � 1"•,- Contractor's License HALEY"953DP Expires 3/17/2017 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOP NEW 8X8 SPA POOL SEP11-00031 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 55,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: 64 CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $622.00 SRE 06/09/15 156141 Plan Check $404.30 SRE 06/09/15 156141 State Building Code $4.50 SRE 06/09/15 156141 Total: $1,030.80 1\firlomnrlArinfn1fnnnmckr RI n Ann Rid rnf R,O/9l11S • • 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) Q (P" sq/ft Sidewalks sq/ft Sidewalks 14A sq/ft Patios sq/ft Patios a-(f(' sq/ft Solid Decks sq/ft Solid Decks -5so sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc ,1 sglft Driveway, parking, roads, etc (6 t ' sq/ft Other (©6 sq/ft Other sq/ft Total New ((0 _sglft Total Existing (4,6 `((cf sq/ft TOTAL NEW+TOTAL EXISTING* 1 4 144 sgift *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:;26A I 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 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. (LAND• 'OR A HOR' "EPRES•NTATIVE'IGNATURE) (DATE FOR OFFICE USE ONLY SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No siorenvaier talc worksheet Rev 9-9-2010—REV 91912010 2 • • � A) CO, JEFFERSON COUNTY .- DEPARTMENT OF COMMUNITY DEVELOPMENT . . 621 Sheridan Street • Port Townsend • Washington 98368 y,s∎,x, ,.(.0 O 360/379-4450 • 360/379-4451 Fax http://www.cojefferson.wa.us/commdevelopment/ 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 G t 1 acres ' An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet .2Q(7, - "' ' 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 aA acres or more of Construction site for structures (0 Oi sq/ft native vegetation to lawn or landscaped areas? Drainfield,septic tank,etc. 0 sq/ft Circle: Yes G Well, utilities,etc. n sq/ft Does the project convert 2'/:acres or more of native vegetation to pasture? Driveway, parking,roads,etc. 0 sq/ft Circle: Yes Nod Lawn, landscaping, etc. 0 sq/ft Other compacted surface, etc. 0 sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance (0 0 sq/ft Cut j Fill (cu/yd) [over] stormwater oalc worksheet Rev 9-9-2010—REV 9/9/2010 • • i'v' Cpe, DEPARTMENT OF COMMUNITY DEVELOPMENT 4, `�` 621 Sheridan Street,Port Townsend,A\'A 98368 W Tel 360.379.4-b) I Fax.360.379. 51 \V'eb:www.co.leffergon.wa us/communitydevelopment F-mail dcdc co.iefferson.W3.us pS41 N G - PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application; it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Budding Permit# Related Application#si MLA# Site Information Assessor Tax Parcel Number: 901051001 Site Address and/or Directions to Property:6411 SH 20 Port townsend, WA. 98368 Access (name of street(s)) from which access will be gained: SR 20, Existing driveway Present use of property: Residential Description of Work(include pr osed uses): Install New Exercise Spa 1 i ,ic,,,_ Y Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ _ NO V If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: J Septic Septic Permit#: Q(V\ I I _ 000 ? I Community Septic Name of System: Case#: Are other residences connected to the septic system? NO Additions or repairs to sewage system: NO Is it a complete or partial system installation: Complete V Partial Has a reserve drainfield been designated? Yes _ve No Date of Last Operations& Maintenance check: 07/15/2014 Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: None The authorized agent/representative . primary contact for all project-related qu ns and correspondence. The County will mail / e-mail requests and information a out 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 Owner: Name: Michael, Bair Address: 5411 Highway 20 Port Townsend Wa. 98368 Phone#: 360-379-4692 , . _ E-mail Address: mbbairl l (.gmail.com %/ Please con-:• t ,• ized nt/Representative with project info. (select only one). — — / Property Owner Signature: Date: / 2 915 Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative Of other than owner) Name: Tim Masbruch DBA Haleyco Gen. Contractor#cchaley**953dp Address: PO Box 441, Vaughn, Wa. 98394-0441 Phone#: 253-677-4474 E-mail Address: haleycompany @gmail.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 anti that they will be ass ing the responsibility of the General Contractor for the proposed project. \ Tim Masbruch Signatur-. ,' A Print Name: Date: ,/Q 70/, SON co DEPARTMIT OF COMMUNITY DEVELOPMENT �U G 621 Sheridan Street,Port Townsend,WA 98368 W 1- Tel:360.379.4450 Fax:360.379.4451 ti '' Web:www.co.jefferson.wa.us/communitydevelopment '' E-mail:dcd@co.jefferson.wa.us k,,SI,I NC;c° SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt#: Date: Related Application#5: Payment#: Site Information , t Owner Name: (V\ clACA ( ( Assessor Tax Parcel#: eT'e5 /d /670 ( Type of Building New )C Replacement Relocated Addition Repair Demolition * *A separate permit is required Select One: PCI�q P p, '6,..Y-.. Single Family Residence Modular Other list Proposed Building/Project fi<< Number of floors A # 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 ./t> .a ' Garage 2nd fl-finished space or habitable Carport-2 walls or less Deck-uncovered Covered porch Other(shed, barn, pole bldg,etc.) S e A (j� Estimated Cost of Project (Required): $ 6 :. $ Supplemental SFI-t I • List existing buildings on property (house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use 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 to this application packet may result in making any issued permit null and void. Signature: Print Name: Date: T' nv4 ¢ - N For Deparkmentl)Se`Dr�IY Building Permit Fees Building Base �` °60 Plan Check Review Land Use Review $234.00 Septic Review $129.00 Potable Water Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption 5y 00 Zoning Zoning Other New Address Total Fees Receipt # Date: Cash/Check/CC: 4��I:mvni.d ti 192