HomeMy WebLinkAboutBLD2015-00128 - 01 PERMIT APPLICATION • BUILDING PERMIT APPLICfION BRD1e OOpe:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00128 Received Date: 4/15/2015
SITE ADDRESS: 250 SADDLETREE DR
PORT TOWNSEND, 98368
OWNER: PAUL W LOUBERE PHONE: 360-385-7156
FRANCES A LOUBERE
250 SADDLETREE DR
PORT TOWNSEND WA 98368-9813 9650
SUBDIVISION: Block: Lot: 94
PARCEL NUMBER: 965000088 Section: 27 Township: 30 N Range: 1\A
CONTRACTOR: KELLEY SHIELDS INC PHONE: (360) 385-7156
260 KALA POINT DR
PORT TOWNSEND WA 98368
Contractor's License KELLES1150LF Expires 6/6/2015
REPRESENTATIVE: KELLEY SHIELDS INC PHONE: (360) 385-7156
DENNIS KELLEY (360) 385-3115
260 KALA POINT DR
PROJECT DESCRIPTION NEW DECK
SEP10-00069
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 11,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: SETBACK:
DECK: 219
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 $168.00 SRE 04/15/15 154328
Plan Check $109.20 SRE 04/15/15 154328 APPROVED
State Building Code $4.50 SRE 04/15/15 154328 APR 14 2015
Total: $281.70
Jefferson County DCD
11tidemark\data\forms\F_BLD_App_Bld.rpt 4/15/2015
• BUILDING PERMIT APPLICATION BRLD1e 0011228
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00128 Received Date: 4/15/2015
SITE ADDRESS: 250 SADDLETREE DR
PORT TOWNSEND, 98368
OWNER: PAUL W LOUBERE PHONE: 360-385-7156
FRANCES A LOUBERE
250 SADDLETREE DR
PORT TOWNSEND WA 98368-9813 9650
SUBDIVISION: Block: Lot: 94
PARCEL NUMBER: 965000088 Section: 27 Township: 30 N Range: 1V1
CONTRACTOR: KELLEY SHIELDS INC PHONE: (360) 385-7156
260 KALA POINT DR
PORT TOWNSEND WA 98368
Contractor's License KELLESI150LF Expires 6/6/2015
REPRESENTATIVE: KELLEY SHIELDS INC PHONE: (360) 385-7156
DENNIS KELLEY (360) 385-3115
260 KALA POINT DR
PROJECT DESCRIPTIOP NEW DECK
SEP10-00069
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEK MAIN:
VALUATION 11,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: SETBACK:
DECK: 219
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 $168.00 SRE 04/15/15 154328
Plan Check $109.20 SRE 04/15/15 154328
State Building Code $4.50 SRE 04/15/15 154328
Total: $281.70
11tidemarkldatalforms\F_BLD_App_Bld.rpt 4/15/2015
• •
w�SON cOG DEPARTMENT OF COMMUNITY DEVELOPMENT
4 4" 621 Sheridan Street,Port Townsend,t\'_1 98368
W Tel:360.3-9.4450 1 l :360.3?9.44i1 neoell ,/,_Web:WMW.0o.icfferson.wa.us/commmnitydevel∎Tment dcd(!a,.iefferiun.wa.us
‘-7 17)
'4o
n
PERMIT APPLICATION
Steps in the Permit Process: P' CT Cppgh,�UlVI,'YC U(V f}
-Review application checklist to ensure all information is completed prior to submitting application. 6Q(7PMENT
-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: c(6S 000 0 IRg
Site Address and/or Directions to Property:
Z �=i IA 71136b L 4r 'TDw i-'c -.D
Access(name of street(s)) from which access will be gained:
S P I.Acr f•t:
Present use of property: rj 2 t 9
Description of Work(include proposed uses):
,•� EA) P E . A- -DaZ.L w f /N ct,u
v.1 c? -& { o -- DO z o c 'au- - l.)-)4I r S /J o-
CpI..,S1–P-11 c–m-
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO S
If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
Septic Septic Permit#: S')LP - a 9
Community Septic Name of System: Case#:
Are other residences connected to the septic system?
Additions or repairs to sewage system:
Is it a complete or partial system installation: Complete _ Partial _
Has a reserve drainfield been designated? Yes No
Date of Last Operations& Maintenance check: Attach last report to application
Describe or attach any drainfield easements,covenants or notices on title,which may impact the property:
• •
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(i.e.,County email is not blocked or sent to"junk mail").
Applicant/Property Owner Information
Property Owner: J
Name: �it,,.. (.-QU 13 -12.E. _
Address: 25t SPA>buz r lam _' `
Phone#: _ �j�0 -121s5--0-6(9 Email Address: c. .,lrlc ua niy p-ft/S_ h '
ease contact Authorized Agent/Representative with project info. (select only one).C
—
Property Owner Signature: Date: '5/us. /! 7
Note: For projects with multiple owners,attach� te sheet with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative Of other than owner)
Name: (G(Q,L, m'`( &b4-i t.O5 / 1-)G . ---7( is cot/ f-
Address: ‘2,..t4,0 `C-fcr4 Y L . Di'-• R_)124- TOL)i-CC711>-- J
Phone#: '3 60 -3s-$--Li 5k, E-mail Address: 61511, eidc t' a, ktiu KT
ro ssional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer u Architect Surveyor Contractor Consultant
Name: -1)e}..r-(C> Ist-I c
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 -_ -6onsultan _�
Name: i Ci /7 r`
-_� Address: l
Phone#: E-mail Address: , ( ', • I:, �)'
Attach additional pages if necessary ; I !t
,.___"1
Builders Statement i) , ;r,A,rnir
The signer of this statement certifies that the are the Owners the parcel referenced herein,that they are riot licensed-'
contractors and that they will be assuming the r ponsibili of the General Contractor for the proposed project.
Signature: Print Name. Date:
��ON co DEPA•ENT OF COMMUNITY D$ELOP _ T
kt4 6. 621 Sheridan Street,Port Townsend,WA 98 368 /'�
Tel:360.379.4 450 I Fax:3603-'9.4451
\\'e1 ww‘v.co.ietterson.wa.us us commumr deg elopment / r �� 1 �
E-mail:dcdr co.iefferson.wa.us / ! .'
9skrNO� SUPPT.EMENTAL APPLICATION fl
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt#: date�i,
on4,7EM
Related Application#s: Payment#:
Site Information
Qwner Name: jFtJi, (rptji),xs - Assessor Tax Parcel#: 7(O j 000 QM
Type of Building
New Replacement Relocated
Addition ' etc-- Repair Demolition
'A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors #new bedrooms existing total bed
' #new bathrooms existing total bath
Heat Source
Select all that apply:
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office Use)
Residential/Commercial Main Floor
Residential/Commercial Second Floor
Additional Floors-heated/unheated
Basement-unfinished •
Basement-finished space or habitable
Detached Garage- heated/unheated
Attached Garage- heated/ unheated
Garage 2nd fl- unfinished storage
Garage 2nd fl-finished space or habitable
Carport-2 walls or less
Deck- uncovered 21c1
Covered porch
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ t )/,p� C)
• •
• List existing buildings on property(i.e. house, garage,accessory dwelling unit, shed, barn, mobile home,other):
All Existing Buildings on Property Use
P' {c
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: Y'i Print Name: ?arJtr �(�rL�
Date: • -) 3) j
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
Building Base j (per U C3
Plan Check Review 1 0 9 - �-U
Land Use Review $234.00
Septic Review $80.00
Potable Water
Technology/Scan $19.50
State Fee $4.50
Other Fees
lajn
Shoreline Exemption Oeu we
Zoning app
10
Zoning
_J („ Cfi^✓1�(I�r� vUPdTY
Other Ti DEVF ppMENT
New Address
Road Approach
Total Fees �ii �j -
Receipt # Date: Cash/Check/CC:
• •
¢5ON ��� JEFFERSON COUNTY ��
• DEPARTMENT OF COMMUNITY DEVELOPMENT
��
h � � C
621 Sheridan Street • Port Townsend Washington 98368 I APR
0,
N0,r0 360/379-4450 • 360/379-4451 Fax
http://www.co.jefferson.wa.us/commdevelopment/ lEF SO`
UFPr R
pF�d�fryU""rDE Etop MEArr
Stormwater Calculation Worksheet Jf
MLA# PROJECT/APPLICANT NAME: (Jt5l_114r- •ZLL
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 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 22\ too b 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 c:31) sq/ft native vegetation to lawn or landscaped areas?
Drainfield, septic tank, etc. sq/ft Circle: Yes No
Well,utilities, etc. sq/ft Does the project convert 2'A acres or more of
native vegetation to pasture?
Driveway, parking, roads, etc. sq/ft
Circle: Yes No
Lawn, landscaping, etc. sq/ft
Other compacted surface, etc. sq/ft Indicate Tot I Volumes of Proposed:
Total Land Disturbance 1100 sq/ft Cut Fill (cu/yd)
[over]
• •
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) \ Zeo sq/ft
Sidewalks sq/ft Sidewalks b0 sq/ft
Patios 7/7i_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 SC) sq/ft
Other / sq/ft Other sq/ft
Total New sq/ft Total Existing Z 1(00 sq/ft
TOTAL NEW+TOTAL EXISTING* sq/ft This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v. REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage:
Does the site have 35%or more of existing impervious surface? Circle: Yes No
FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be
used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the
attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum
Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements.
For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution
Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and
prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction
Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of"medium" projects—those
that must meet only Minimum Requirements #1 through #5—and for "large" projects—those that must meet all 10 Minimum
Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan,
principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or
prepare a Stormwater Site Plan using the step-by-step guidance in the 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 IF
101/ 1A//‘--$7Z— Ct•
r-(LrNDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
FOROF{FILE USF ONLY li
1��� I'S+s�MSY4�f�A} 1 t�klpi"yNWT'�]� - .. .
?�'{ MEDIUMS�+ .,,,LARGER.- ,4a�.REDEVELOPMENT Stormwater Plan:
Yes . . No
sto rmwater calc worksheet—REV. 11 r5/2008 9
_ _ • •
. ,.
4 .
/4ON c06 DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
W Tel:360.379.4450 Fax:360.379.4151 E C E O R V/J
Web:www.co.Jefferson.wa.us/conununitydevelopment
E-mail:dcda.co.iefferson.wa.us
1SHr N6�o APR 1 0 275
PERMIT APPLICATION _
JEFFERSON COUNTY
Steps in the Permit Process: --- 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#s: MLA#
Site Information p�
Assessor Tax Parcel Number: q' (5 coo 0 gp
Site Address and/or Directions to Property:
Za S M>bLAZ TQk L.
t��-r- Taw wcL>-
Access(name of street(s)) from which access will be gained:
Present use of property: S. c T)– > t 9 C -
Description of Work(include proposed uses):
G NR' 7 A- -D6-u bA- / lJcc .uQ
0 v..1 F t✓s — 00 Z O CA 'BUT" S r.)(T
V Wastewater-Sewage Disposal
9 This property is served by Port Townsend of Port Ludlow sewer system? YES NO
CL) If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
---f_Septic Septic Permit#: St:P 10 t Q t U(( 9
Community Septic Name of System: Case#:
Are other residences connected to the septic system?
Additions or repairs to sewage system:
Is it a complete or partial system installation: Complete _ Partial
Has a reserve drainfield been designated? Yes _ _ No
Date of Last Operations&Maintenance check: Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title,which may impact the property:
• •
, 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(i.e.,County email is not blocked or sent to"junk mail").
Applicant/Property Owner Information
Property Owner: J
Name: 1, L-00 5e-il k>
Address: 2255 P10IX ill.- 6r L
Phone#: _ -5‘.,0 .12 5-'lt'J(e E-mail Address: ,A,,)►,t2ta_c 2_ 6('-( Wpi a Ylr
$ease contact Authorized Agent/Representative with project info. (select only one).C lr
—
Property Owner Signature: - j, Jt� Date: 3/ / j
Note: For projects with multiple owners,attach a sep with each owner(s)information and signatures.
Applicant: Authorized Agent/Representative Of other than owner)
(Lat..(Lt.. c'`( St+l E-t-D 5 / N—& - , -- Iiic Cat/ escp.,G
Address: EZ D lC.'Pc 4' Y . i".)/E-' f)e TD())/- CMfi>.-
Phone#: -3 bo -3 - 11scf., E-mail Address: clCylreldc a Oil WPus. K;T
ro ssional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer y Architect Surveyor Contractor Consultant
Name: ."DC 'r-IX? cell(.5-1-1),c
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: IL =--°�' = I �ti7��
Phone#: E-mail Address: j;�,
Irl .
Attach additional pages if necessary i 1
Builders Statement -
The signer of this statement certifies that the are the Owners • the parcel referenced herein,that they are'not t cepsed
contractors and that they will be assuming the r: ponsibili of the General Contractor for the proposed project. ' '-
Signature: Print Name. Date:
�gON e DEPARTMENT OF COMMUNITY DEILOPM T
�j 621 Sheridan Street,Port Townsend,nsend,\\_\98368
<L Tel-360.379.4450 Fas:3603 79.4-4d l 1D E C I L� D M S
ti •t \\'eb:w ww.co.iefferson.��a.us'commwvndecelopment I
E-mail:dcdaco.iefferson.wa.us 'n
1 f I l 7
RSkf N OHO SUPPLEMENTAL APPLICATION I uII .1 I
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
Or C(rdLti�ip, .
For Department Use Only Receipt#: Date:
Related Application#s: Payment#:
Site Information
Owner Name: (.O tie-ASj? Assessor Tax Parcel#: q0 Ova 0 S
Type of Building
New Replacement Relocated
Addition 'pi x_- Repair Demolition
'A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors #new bedrooms existing total bed
IP #new bathrooms existing total bath
Heat Source
Select all that apply: i�
Electric Heating Oil �� i' 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 ZIct
Covered porch
Other(shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ t yoc 1 ' $ (#.2_q i O
• •
List existing buildings on property(i.e. house,garage,accessory dwelling unit,shed, barn, mobile home,other):
All Existing Buildings on Property Use
"C5Ltrit4Vela 64n1(1-04C2
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: k, , � ,_.,� Print Name: T Prclt— Lpvy+•,t., -- Date: Al 3) tj
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:
IFor Department Use Only
Building Permit Fees
Building Base I (per - U U
Plan Check Review i09 - 10
Land Use Review $234.00
Septic Review $80.00
Potable Water ' 094161—
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning (�
Other D IS O
New Address /�A
Road Approach 1
1.FFERSOIv'COU
_ ,D.P7 OFCOPAPnUNI1YD NP( ( r� �-� . Z�
•Total Fees E�`10PMENT `Y
Receipt # Date: Cash/Check/CC:
/
�.g,$ON iko JEFFERSON COUNTY ��al �� DEPARTMENT OF COMMUNITY DEVELOPMENT � � �U f � '�
Ip �/
621 Sheridan Street Port Townsend Washington 98368/
.q O 360/379-4450 • 360/379-4451 Fax " ""- II/p. £F
S' NOBS- http://www.co.jefferson.wa.us/commdevelopment/ oF6O,,,''6 pUtiry
0��£CO4 47,
Stormwater Calculation Worksheet
MLA# PROJECT/APPLICANT NAME: J O(Ii,l_7Le-- L./12-UL-
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)
i
Size of parcel acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 22 boo 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 I a=0 sq/ft native vegetation to lawn or landscaped areas?
Drainfield, septic tank, etc. sq/ft Circle: Yes No
Well,utilities, etc. sq/ft Does the project convert 2'h acres or more of
native vegetation to pasture?
Driveway, parking, roads,etc. sq/ft
Circle: Yes No
Lawn, landscaping, etc. sq/ft
Other compacted surface, etc. sq/ft Indicate Tot I Volumes of Proposed:
Total Land Disturbance loo sq/ft Cut Fill (culyd)
lover"
. 0
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) l�Zap sq/ft
Sidewalks sq/ft Sidewalks t t ■D 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 '6D sq/ft
Other / sq/ft Other ' sq/ft
Total New sq/ft Total Existing ;Aeon sq/ft
V
TOTAL NEW+TOTAL EXISTING* sq/ft *This amount will be used to check total lot coverage.
The following questions will help determine whether the proposed project is considered development or redevelopment.
DEVELOPMENT v.REDEVELOPMENT
Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: a
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 S
..--e / 1/1// -C3-7- k 1 CV)I "S-
DOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
I FORs`OFF/CE USE ONLY': < 4 + F
a .fir: ,4 0 ,-'
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S • •.
•
shod Excavating Inc. ■
PO Box 179 . 360485-0480
Port Hadlock, WA 98339
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PROPERTY INFORMATION //�
Location-250 Saddletree Dr %J /
4F•_
Port Townsend ; r
Tax ID:965000088
Ma,To PAUL LOUBERE
Use:Residential, Single 'j?/'- ,
CUify0,,�V /I _ `� ``
Owner PAUL LOUBERE
ON ID:SOM1 obi't i'
Foil T-6 ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT Fold
Hew tare
Inspected:04/9212015 - Inspection Type:ROUTINE - Correction Status:No corrections needed
Company: Certification-Level Work Performed 8y: Submitted 04/02/2015 by:
Shold Excavating Inc. Martin Fugere Martin Fugere ■
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: Fuly Inspected
Al Components accessible for maintenance,secure and in good condition: YES
Surfacing effluent from any component(including mound seepage* NO
Components appear to be water tight-no visual Isaias 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 NIA
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? WA
(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 I
describe in notes):
The house/structure was vacant or used infrequently,axe:weaned of the dainfm eld was not possible. NO
la the SEP case in a tinaledlconpietad status?(If NO explain in comments) YES
ONSITE SEWAGE SYSTEM INSPECTION DETAIL
TANK:Septic Tank-2 Compartment
This component was: Fray Inspected
Component appears to be functioning as intended: YES
Effluent level within operational limits(d NO explain in comments): YES
Al required baffles in place(N/A=No bates rewired): YES
Effluent Fitter Cleaned(N/A=Not Present): YES
Compartment 1 Scum accumulation(Inches,if other specify): s'
Effluent fitter/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'
Pumping needed: Na
Approximate Gallons to be purnped(if needed)by Certified Pumper. 0
w ..
•istribution.D-Box
This component was: Fully Inspected
D-Box in good condition: YES
D-Box outlets set to allow equal effluent distribution' YES
•rainfi eld:Gravity
This component was Fully Inspected
Component appears to be functioning as intended: YES
Ponding present?It YES explain in comments: NO
i -
-`-.M1ry
N� ��NTY
/i/ 0 4 jll
�OfVflOnMf�T
Mg report Andantes certain charactenstcs of the ons to sewage system at the hereof esi re no way is this report a guarantee dopiratoe or future performance