HomeMy WebLinkAboutBLD2015-00152 - 01 PERMIT APPLICATION •UILDING PERMIT APPLICA1 N BLD15-00152
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00152 Received Date: 5/1/2015
SITE ADDRESS: 313 NESS' CORNER RD
PORT HADLOCK, 98339
OWNER: CHIMACUM SCHOOL DIST#49 PHONE: 360-732-4090
PO BOX 278
91 WEST VALLEY RD
CHIMACUM WA 98325-0278
SUBDIVISION: Block: Lot: T 196
PARCEL NUMBER: 901023010 Section: 2 Township: 29 N Range: 10
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: TERRAPIN ARCHITECTURE PHONE: 360-379-8090
727 TAYLOR ST
PORT TOWNSEND WA 98368
PROJECT DESCRIPTIOI INSTALL NEW BICYCLE SHELTER 29X 28 INCLUDING RACKS &
CONCRETE PAD
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: 494
TYPE OF IMP NEW MAIN: INDUSTRIAL:
VALUATION 9,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS:
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $146.00 SRE 05/01/15 155971 A��
Plan Check $94.90 SRE 05/01/15 155971 ROVED
State Building Code $4.50 SRE 05/01/15 155971 MAY 9
Total: $245.40 2915
Jefferson County DCD
\\tidemark\data\forms\F_BLD_App_Bld.rpt 5/1/2015
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co DEPARTMENT OF COMMUNITY DEVELOPMENT
% \621 Sheridan Street,Port Townsend, A 98368
W Tet 360.379.4450 I Fax:360.379.4351
Web:www.co.Jefferson.wa.uskommunitvdeveloptnent
9 ___ AVE
9 C1� E-mail:dcd nico.iefferson.wa.us r--------_ _ .�
SHiNG� APR 3 0 ?015 �1i
PERMIT APPLICATION
JEFFERSCPi Ct,DfdTY
Steps in the Permit Process: 1.____ DEPT OF COMMUNITY DEVFLOPMENT
-Review application checklist to ensure all information is completed prior to submitting alp-PIT-cation.
-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: 9C / 025 C l O
Site Address and/or Directions to Property: 313 N ES5 GOZN gi
?60-T HA-DL cX, V.J,r RS33`1
Access(name of street(s)) from which access will be gained: N E55 Cog.N,— ?.t - SQ- l
ei
Present use of property: CHIMPrCV M C.eEEI - pg11'-4114-IZY SCHOOL *41
Description of Work(include proposed uses): NEW $ICY Cl. S H E I.TEI ,
11`IGI.U1) (14(p leA-CICS t_ C6IJCeeTF
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:
_ 1,/ Septic Septic Permit#: 5e17 9S -CC (31
_ _ Community Septic Name of System: Case#:
Are other residences connected to the septic system? NO
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: It)ht- 2.0('' - 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 ill/primary contact for all project-related quest 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: C.4-4- I M A GVM S G fr{ jL ]) LS1IZICT
Address: 6(( WEST VM-UEY �b.I OA INIAcuM, wA 6'1 325
Phone#: _ 360 - 732 -4/0TO E-mail Address:
Plea t Authorized Agent/Representative with project info. (select only one).
Property Owner Signatu • a-_,.. Date: / .2y /_j
Note: For projects with multiple owners,at ch a separate sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative (it other than owner)
Name:
Address:
Phone#: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO ES
Engineer ArchitX Surveyor Contractor Consultant
Name: "T12-IZAs.PIN AF-GH1-CeCrU0e-
Address: 1 V7 lrlkfLO0- Sr
Phone#: L3(6,(3 ) 3-749 -gpgO E-mail Address: r LC_�jlard&-t--eer;ra p i4-al-J' c,
Professional: Is this an Authorized Agent/Representative for this project? (NO) YES
Engineer Architect Surveyor Contractor Consultant
Name: e2 ENGINEERS
Address: 1S ((o I tS-5rc ?L . Nei Ke1-1MDgE, uA ctsazg
Phone#: G(2c - 216- 249 O3 E-mail Address: Vl,jo,sci Qb2eAncneef S . COM
Professional: Is this an Authorized Agent/Representative for this project? NO YES j
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
contrac : . , that they wi be assuming the responsibilit of the Gener I Contractor forfothe proposed proj ct.
Signat , Print Name: SLs� /� l Date: y �q ��
1
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DEPARTMENT OF COMMUNITY DEVELOPMENT
(� ��i� ; '.�E mail.dcd(a'co.iefferson.wa us n - �SUPPLEMENTAL APPLICATIO n, I1 11
RESIDENTIAL OR COMMERCIAL BLDG $IERMIT __,
For Department Use Only Receipt#: I' , n'c,,,.�y1 �t� 9f+ jn "_ ._ s
Related Application#5: Payment#:
Site Informal s
Owner Name J Assessor Tax Parcel#: GPO f OZ3D /D
Ch vil4Cl1 )
Type of Building
New ✓ Replacement Relocated
Addition Repair Demolition *
*A separate permit is required
Select One: $IDYLL.e--
Single
Single Family Residence Modular Other SH. L'f6RZ list
Proposed Building/Project ',
Number of floors ( #new bedrooms ,O' existing total bed
# new bathrooms „gr.' existing total bath
Heat Source
Select all that apply: r✓/A-
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure , Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement- unfinished
Basement-finished space or habitable
Detached Garage - heated/unheated
Attached Garage-heated/unheated
Garage 2nd fl- unfinished storage
Garage 2nd fl-finished space or habitable
Carport-2 walls or less
Deck- uncovered
Covered porch
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ 9[ 000
•~ •
List existing buildings on property (i.e. house,garage, accessory dwelling unit, shearn, mobile home, other):
All Existing Buildings on Property Use
CNIMAaiM CE �K_ t _3CHOO L �i;UC�artO
C2 -) SHPr)S FGtU►PMN T ST QAGE
By signing this application form, the owner/agent attests that the information pr Vlrein, and in any"aftac m: ts, is
true and correct to the best of his, her or its knowledge. Any material falsehood any-omission of a material fac ade
by the owner/agent with respect to this application packet may result in making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed-]
in compliance with all applicable federal, state and county laws and regulations and I agree to provide access and
right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
review and any required later inspections. Applicant may request notice of the County's intent to enter upon the
property for visits related to this application and subsequent permit issuance.
Signatur c .(( i--- Print Name:.---- /c h S1�ca r� Date: _ _/*
Estimated Cost of Project $
For Department Use Only
Building Base Fees
Building Base (yam00
Plan Check Review Iy q O ' I
Land Use Review -$`t :AO_ Z3`4
Septic Review 0a
Potable Water -31,715;72-11 -
Technology/Scan $19.00
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt # Date: Cash/Check/CC:
• •
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(-9SoN .cow DEPARTMENT OF COMMUNITY DEVELOPMENT 1
rf'•f C''''''.4. .k 621 Sheridan Street,Port Townsend,WA 98368
'`4 Tel:360379.4450 � Fax:360379.4451 -- •L" n \\( g
Web:www.co.iefferson.wa.us/communitydevelopment
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E-mail:dcd(a%co.jefferson.wa.us ry
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STORMWATER CALCULATION WORKSH '41`: J,,;
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 L0.-74 acres An
An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 4i 353 +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 Y.acres or more of
Construction site for structures !-._ sq/ft native vegetation to lawn or landscaped areas?
Drainfield,septic tank, etc. F,)(IST IN Co sq/ft Circle: Yes io
Well, utilities,etc. sq/ft Does the project convert 2'/2 acres or more of
native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft
Circle: Yes &
Lawn, landscaping,etc. sq/ft
Other compacted surface, etc. V sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance / sq/ft Cut Fill - (cu/yd)
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural
conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an
increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include,
but are not limited to roof tops,walkways, patios,driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads,
packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.
stormwater cabs worksheet—REV.10120!2014 1
• •
STORMWATER CALULATIONS—IMPERVIOUS SURFACE
NEW ���t EXISTING 1
Structures (all roof area) li 1 if sq/ft Structures (all roof area) TO eM4I I' sq/ft
Sidewalks sq/ft Sidewalks sq/ft
Patios sq/ft Patios sq/ft
Solid Decks sq/ft Solid Decks sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking, roads, etc sq/ft Driveway, parking, roads, etc sq/ft
`r
s
Other sq/ft Other q/ft
Total New 491- sq/ft Total Existing TD 469t/A14 sq/ft
APP!7'ioNA
TOTAL NEW+ TOTAL EXISTING* `I4 sq/ft *This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v. REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: %
Does the site have 35%or more of existing impervious surface? Circle: Yes No
it
-\ ( I`� 11 \\
FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the hed Figure 2 shoiul II s
to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development ari t
attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine t
Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the applica i
requirements. �I
For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwattr Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elententi1b_ibr it rrisien—
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. cc
�L-1J� li/ ATE/s
LANDOWN R OR AUTHORIZED REPRESENTATIVE SIGNATURE)
0RQFffGF9OMEY ( II - ti 4 r V Pn : m f {1 vii '..
'r 1 k: l . � i it tilt
0iIll I [sM' ,51q
`T'
ai ;] eulUMf rta tF [ota �Jtormv1.$61-5ite.-y1.in ;Q 1 r: 1114'''17'.
stormwater cal::worksheet—REV.10/20/2014 2
• •
FIGURE 2: REDEVELOPMENT
Do the new, replaced, or new plus replaced impervious surfaces total 2,000
square feet or more?
OR
Does the land disturbing activity total 7,000 square feet or more?
Yes 'b
T"MEDIUM" PROJECT " PROJECT
Minimum Requirements#1 through#5 equirement#2,
apply to the new and replaced impervious water Pollution
surfaces and the land disturbed.
Next Question
Does the project add 5,000 square feet or more of new impervious surfaces?
OR
Convert 3/4 acres or more of native vegetation to lawn or landscaped areas?
OR
Convert 2.5 acres or more of native vegetation to pasture?
Yes No
j Next
"LARGE"PROJECT Question Is this aroad-
•
Minimum Requirements#1 through#10 related project?
apply to the new impervious surfaces Y�
and the converted pervious surfaces. No
Ae
Does the project add 5,000 square feet or more of new impervious surfaces?
Yes No
Do new impervious surfaces add 50%or Is the total of the new plus replaced
more to the existing impervious surfaces impervious surfaces 5,000 square feet or
within the project limits? more, AND does the value of the
proposed improvements—including
No Yes interior improvements—exceed 50% of
j the assessed value (or replacement value)
No additional
I
of the existing site improvements?
Ill
requirements Yes No
I No additional
requirements
Minimum Requirements#1 through#10
apply to the new and replaced
impervious surfaces.
Based on Fig.2.3 from 2001 Ecology Stormwater Management Manual for Western Washington
Table 8402.1.1 Footnotes
• For SI: 1 foot .=304.8 mm, ci .=continuous insulation, int .=intermediate framing
a R-values are minimums. U-factors and SHGC are maximums. When insulation is installed in a cavity which is
less than the label or design thickness of the insulation,the compressed R-value of the insulation from
Appendix Table A101.4 shall not be less than the R-value specified in the table.
b The fenestration U-factor column excludes skylights.The SHGC column applies to all glazed fenestration.
Exception:Skylights may be excluded from glazed fenestration SHGC requirements in Climate Zones 1
through 3 where the SHGC for such skylights does not exceed 0.30.
`"10/15/21.+TB" means R-10 continuous insulation on the exterior of the wall,or R-15 on the continuous
insulation on the interior of the wall, or R-21 cavity insulation plus a thermal break between the slab and the
basement wall at the interior of the basement wall. "10/15/21.+TB" shall be permitted to be met with R-13
cavity insulation on the interior of the basement wall plus R-5 continuous insulation on the interior or
exterior of the wall. "10/13" means R-10 continuous insulation on the interior or exterior of the home or R-
13 cavity insulation at the interior of the basement wall. "TB" means thermal break between floor slab and
basement wall.
a R-10 continuous insulation is required under heated slab on grade floors.See R402.2.9.1.
e There are no SHGC requirements in the Marine Zone.
Basement wall insulation is not required in warm-humid locations as defined by Figure R301.1 and Table
R301.1.
g Reserved.
h First value is cavity insulation,second is continuous insulation or insulated siding, so "13.+5" means R-13
cavity insulation plus R-5 continuous insulation or insulated siding. If structural sheathing covers 40 percent
or less of the exterior, continuous insulation R-value shall be permitted to be reduced by no more than R-3 in
the locations where structural sheathing is used to maintain a consistent total sheathing thickness.
The second R-value applies when more than half the insulation is on the interior of the mass wall.
For single rafter-or joist-vaulted ceilings,the insulation may be reduced to R-38.
k Int. (intermediate framing) denotes standard framing 16 inches on center with headers insulated with a
minimum of R-10 insulation.
Log and solid timber walls with a minimum average thickness of 3.5 inches are exempt from this insulation
requirement.
Table R402.1.3 Footnote
a Nonfenestration U-factors shall be obtained from measurement,calculation or an approved source or as
specified in Section-R402.1.3. T__.__
• Df f
BUILDING PERMIT APPLICATION BR view T pet
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00152 Received Date: 5/1/2015
SITE ADDRESS: 313 NESS' CORNER RD
PORT HADLOCK, 98339
OWNER: CHIMACUM SCHOOL DIST#49 PHONE: 360-732-4090
PO BOX 278
91 WEST VALLEY RD
CHIMACUM WA 98325-0278
SUBDIVISION: Block: Lot: T 196
PARCEL NUMBER: 901023010 Section: 2 Township: 29 N Range: 1111
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: TERRAPIN ARCHITECTURE PHONE: 360-379-8090
727 TAYLOR ST
PORT TOWNSEND WA 98368
PROJECT DESCRIPTIOr INSTALL NEW BICYCLE SHELTER 29X 28 INCLUDING RACKS &
CONCRETE PAD
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: 494
TYPE OF IMP NEW MAIN: INDUSTRIAL:
VALUATION 9,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS:
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $146.00 SRE 05/01/15 155971
Plan Check $94.90 SRE 05/01/15 155971
State Building Code $4.50 SRE 05/01/15 155971
Total: $245.40
\\tidem ark\data\form s1F_BLD_App_Bld.rpt 5/1/2015
• •
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621 Sheridan Sheec,Poet Townsend,W.A.9S3GS
W Tel.360.3 79 4 i50 Pax:360.379.4451
t: .'el :unilv.co.lefferson.ur us;commun h dei elopmtnr L� n/j
x iE
L--mail:dcdfii.co.ieffersonAva.us w/
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In
Li :,cl.
Steps in the Permit Process: , : . , iY
l .0-C0" :1:,DEYDEVELOPMENT
-Review application checklist to ensure all information is completed prior to submitting applica 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: g Q I en 3o le,
Site Address and/or Directions to Property: 31 3 N ESS CO N 'al)
176g-T HAl)LOGK , V - 9'533
Access(name of street(s)) from which access will be gained: N E55 C_c ,E12- T- - S12- (tet
Present use of property: CH I M PrOJ M CZEEK- Pg I M AP< SCHOOL 441
Description of Work (include proposed uses): NEV.) 151C\r' C.t_ S H LT Oa
iN ck.U D (N Co -A-c tc S $ ( c (
FAT
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YESNO
If_not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
%/ Septic Septic Permit#: 5E nets -00 13ci
Community Septic Name of System: Case#:
Are other residences connected to the septic system? ND
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: \Tort- 2 0(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 ilk primary contact for all project-related ques. 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: GI-1- IMkGVM ScI' l_ b1srtZter
Address: I WEST VA1-LEY t-1c)..I CHIMACUM, Wlk `1S 3i
Phone#: _ .360 j2 -Lf t? Q E-mail Address:
- — Plea - . - t Authorized Age t/Representative with project info. (select only one).
Property Owner Signatu •• [�{Jj l Date: g .2 j /5-
Note: For projects with multiple owners,a :ch a separate sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative (if other than owner)
Name:
Address:
Phone If: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO CEO
ES)
Engineer Archite . X Surveyor Contractor Consultant
Name: 1. 12-gA P I N Me-i-11 T OCTi.) "
Address: TAYLC) 51-
Phone ft
rPhone#: ( (,O ) 319 -Socio E-mail Address: rLCl1.?Yds-TCriraOtyt`Z2,r8+i,01111
Professional: - Is this an Authorized Agent/Representative for this project? NO YES
-- Architect Surveyor Contractor Consultant
Name: 82 ANG 1 N EERS
Address: -1 S ((o NE 1C-5r4 ?L., we (4.0.3 E tNA G 8 6 z ie
Phone#: £425- 2'j(o- Zaa3 lE-mail Address: bc ,sri e- b2enoJnee_rs . 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:
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
contra that they wi be assuming the responsibility of the Gener I Contractor for the proposed proj ct.
Signat -• ,,,(53/4"-Print Name: 4t �s' (c.3a Date: y 1f Jr-
• • 1
c DEPARTMENT OF COMMUNITY DEVELOPMENT
(..,..soN
o� 621 Sl eridan SLret Por Townsend R'-1 96368 _Td s�i�1394}30 1ex 3,p3945I � ��� �' -C V eh ww.�r.cn ie*ierson we.us'col imuan de eionn:ent 1 {� .� 1/ �_,
t. C.
E-mail.dcd�tco.ieffel5on�re_us i�, _
--Is -co NG�� SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT ___
For Department Use Only Receipt#: , ,.Date
Related Application#s Payment#:
Site Informat ,
Owner Name k✓ _ _.„.3/1_-__, Assessor Tax Parcel#: GPO/oZ3O /0
C OAddi- 0
Type of Building
New ✓ Replacement Relocated
Addition Repair Demolition *
'A separate permit is required
Select One:
Single Family Residence Modular Other SH5HetKe�I.T�R list
Proposed Building/Project
Number of floors t # new bedrooms ,O' existing total bed
# new bathrooms �42r-- existing total bath
Heat Source
Select all that apply: N/fr
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
<Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor
Residential/Commercial Second Floor
Additional Floors- heated/unheated
Basement- unfinished
Basement-finished space or habitable
Detached Garage- heated/ unheated
Attached Garage-heated/unheated
Garage 2nd fl - unfinished storage
Garage 2nd fl-finished space or habitable
Carport -2 walls or less
Deck- uncovered
Covered porch _
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ 9, DOL9
j; :e;ncn :36iii ti
• •
List oxisting buildings on property (i.e. house, garage, accessory dwelling unit, shea, earn, mobile home, other):
All Existing Buildings on Property Use
GHIMac.J f>r1 c.,E.G.Py _ , SCHOOL. t, T)LIC rto t
(2- SH1.-)1C -CU ;PH NT STPAC7E-
By signing this application form, the owner/agent attests that the information provrde�d.herein, and in any attaoilm �rr{ts, is
true and correct to the best of his, her or its knowledge. Any material falsehood,or any omission of a material fac \nhade
by the owner/agent with respect to this application packet may result in making any issued permit null and void. 0
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed'-;
in compliance with all applicable federal, state and county laws and regulations and I agree to provide access and
right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application i
review and any required later inspections. Applicant may request notice of the County's intent to enter upon the
property for visits related to this application and subsequent permit issuance.
Signatur: __ a. ] ;4 , ' Print Name:7C' J STP.t„(a fL Date: #5—
Estimated Cost o Project $
For Department Use Only
Building Base Fees
Building Base I LI tc -00
Plan Check Review CiLi G O
Land Use Review -- 23(1
Septic Review a CO
Potable Water
Technology/Scan $19.00
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt # Date: Cash/Check/CC:
• •
-S°N .CO DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,\X'A 98368
Tel:360.379.4450 Fax:360.3;9.4431j
' eb:ww- co.iefferson.wa.us/cominututvdevelonmen[ ,; �- {
E-mail:dcdgco.jefferson.wa.us
i '!
STORMWATER CALCULATION WORKSHEET
ro'� TM PROJECT/APPLICANTNAME:
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 (b.75 acres// QQ 2 An acre contains 43,560 square feet. Multiply the acreage by this figure.
'T(OCJ
Size of parcel in square feet 353 -- 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 Geared, 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 Does the project convert/acres or more of_.,
Construction site for structures sq/ft native vegetation to lawn or landscaped areas?
Drainfield, septic tank,etc. E/(51 IN lb sq/ft Circle: Yes 0-o-)
Well, utilities,etc. sq/ft Does the project convert 21 Y2 acres or more of
native vegetation to pasture?
Driveway, parking, roads,etc. sq/ft
Circle: Yes
Lawn, landscaping, etc. sq/ft
Other compacted surface, etc. v sq/ft Indicate Total Volumes of Proposed:
6Total Land Disturbance G,2-- sq/ft Cut tY-
Fill �`�— (cu/yd)
Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural
conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an
increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include,
but are not limited to roof tops,walkways, patios, driveways, parking lots or storage areas,concrete or asphalt paving,gravel roads,
packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater.
stormwater talc worksheet—REV.10/2012014 1
! M
STORM WATER CALULATIONS–IMPERVIOUS SURFACE
NEW �I� EXISTING
Structures(all roof area) 4 1 sq/ft Structures(all roof area) TO EIMA I sq/ft
Sidewalks sq/ft Sidewalks sq/ft
Patios sq/ft Patios sq/ft
Solid Decks sq/ft Solid Decks sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking, roads,etc sq/ft Driveway, parking, roads,etc sq/ft
Other sq/ft Other sq/ft
Total New 49/-1- sq/ft Total Existing (0 (ZE9VAI sglft
APP!TIOK/
TOTAL NEW+TOTAL EXISTING* 411- sq/ft 'This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v. REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage:
Does the site have 35% or more of existing impervious surface? Circle: Yes n No
r-; If1 �/J
FURTHER INSTRUCTIONS: If the answer is yes,the proposal is considered redevelopment and the attached Figure 2 sh ulk s:
to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development a . t •
attached Figure 1. should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine t -
Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the applica
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 12Elements_taconr'�``"rod ecr�sion–
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-
eetall10
Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater
Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal
Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Storm water Management Manual.
APPLICANT SIGNATURE
By signing the Stormwater Calculation Worksheet,I as the applicant/owner attest that the information provided herein is true and correct to the
best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected
property.
•
NDOWN R OR AUTHORIZED REPRESENTATIVE SIGNATURE) ATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No
stoanwaler cal°worksheet—REV.10/20/2014