HomeMy WebLinkAboutBLD2015-00119 - 01 PERMIT APPLICATION BUILDING PERMIT APPLICATION BL
BUILDING
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00119 Received Date: 4/9/2015
SITE ADDRESS: 63 FOUR CORNERS RD
PORT TOWNSEND, 98368
OWNER: JEFFERSON TRANSIT PHONE: 360-385-4777
1615 W SIMS WAY
PORT TOWNSEND WA 98368-3090
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001332009 Section: 33 Township: 30 N Range: 1■.
CONTRACTOR: PEASE CONSTRUCTION PHONE: 253-584-6606
PO BOX 98046
LAKEWOOD WA 98496
Contractor's License PEASECI119OA Expires 9/1/2015
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI 35 FT SELF-SUPPORTING RADIO COMMUNICATION TOWER FOR
JEFFERSON TRANSIT
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP MEC MAIN: INDUSTRIAL:
VALUATION 6,000.00 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:
IR outing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Permit $0.00 SRE 04/09/15
Plan Check $0.00 SRE 04/09/15 APPROVED
Total: $0.00
JUN - 2 2015
Jeff rson County DCD
11 tidemark\data\forms\F_BLD_App_Bld.rpt 4/9/2015
BUILDING PERMIT APPLICATION eview
R00119
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD15-00119 Received Date: 4/9/2015
SITE ADDRESS: 63 FOUR CORNERS RD
PORT TOWNSEND, 98368
OWNER: JEFFERSON TRANSIT PHONE: 360-385-4777
1615WSIMSWAY
PORT TOWNSEND WA 98368-3090
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001332009 Section: 33 Township: 30 N Range: 1V1
CONTRACTOR: PEASE CONSTRUCTION PHONE: 253-584-6606
PO BOX 98046
LAKEWOOD WA 98496
Contractor's License PEASECI1190A Expires 9/1/2015
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP 35 FT SELF-SUPPORTING RADIO COMMUNICATION TOWER FOR
JEFFERSON TRANSIT
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP MEC MAIN: INDUSTRIAL:
VALUATION 6,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS:
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $0.00 SRE 04/09/15
Plan Check $0.00 SRE 04/09/15
Total: $0.00
11 tidemark\data\forms\F_BLD_App_Bld.rpt 4/9/2015
r • 0
��
soN c°U DEPARTMENT OF COMMUNITY DEVELOPMENT
-=, 621 Sheridan Suect,Port Townsend,WA 98368
C 1'cl:360.3-24450 1 Pax:360.379.4451
Web Nview co.icffcraon.u.a.us/eo1r wnitcde celopment
' It-rnaib dcd t co wa us :
PERMIT APPLICATION APR - 9 2015
Steps in the Permit Process: _
-Review application checklist to ensure all information is completed prior to submitting ap lication. JEFFERSON COUNTY
-Make sure septic has been applied for and water availability has been proven. DEPT.OF COMMUNITY DEVELOPMENT ,
-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 if
Related Application#s: MLA#
Site Information
Assessor Tax Parcel Number: 001332009
Site Address and/or Directions to Property:63 Four Corners Road
Port Townsend, WA 98368
Access(name of street(s)) from which access will be gained: Four Corners Road
The site is located on the northeast corner of Four Corners and State Route 20
Present use of property: vacant land
Description of Work(include proposed uses):
The project is to build a 35-ft self- supporting radio communication tower for Jefferson Transit Authority
on the west side of the Maintenance, Operation and Administration Building. This is in association with
the new Maintenance, Operations and Administration Center (BLD14-00004) and MLA13-100.
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#: SEP14-00002
_ _ 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 1 _ Partial
Has a reserve drainfield been designated? Yes ✓— No
Date of Last Operations& Maintenance check: Not complete yet 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 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 snail").
Applicant/Property Owner Information
Property Owner:
Name: Jefferson Transit Authority - Tammi Rubert, General Manager
Address: 1615 W. Sims Way Port Townsend, WA 98368
Phone#: 360-385-4777 ext. 107 E-mail Address: trubert @jeffersontransit.com
Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature: r+-i--7,-- �e Date: /•
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: Samantha Trone, P.E.
Address: 250 Madison Street, Suite 2R, Port Townsend, WA 98368
Phone#: 360-344-4605 E-mail Address: strone @cityofpt.us
Professional: : Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor / Consultant
Name: Pease Construction
Address: P.O. Box 98046 Lakewood, WA 98496
Phone#: 253-606-0506 E-mail Address: tom @peaseinc.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:
Attach additional pages if necessary
Builders Statement
The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed
contractors and that they will be assuming the responsib�of the Generil Contractor for the proposed project.
Signature: �. � j �� Print Name: ���,,", ! �2c� Date: /• /,2.
�s,ON co DEPARTOENT OF COMMUNITY DEVELOP k4 NT
6. 621 Sheridan Street,Port"1 ownsend,WA 98368
Tel:360.379.4450 j Fax:360.379.4451
ti -G Web:www.co.iefferson.wa.us/communitvdevelopment v L.
E-mail:dcd@co.iefferson.wa.us
APR — 9 2
r N ova SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT oura;y
prvrt0'MFNr
For Department Use Only Receipt#: Dater '
Related Application#s: Payment#:
Site Information
•Owner Name: iaj�•!� IL1 liAda Assessor Tax Parcel#: 001 - -D
Type of Building
New X Replacement Relocated
Addition Repair Demolition
'A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors .3- #new bedrooms existing total bed
#new bathrooms existing total bath
Heat.Source
Select all that apply:
Electric Heating Oil Wood Propane
Enter the square footage(sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor 2/ -(p- yr+
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): $ (a,00D
List existing buildings on property (i.•ouse, garage, accessory dwelling unit, shea;'barn, mobile home, other): `
All Existing Buildings on Property Use
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, her or its 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.
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.
Signature:` Print Name: Ikp1-mt,!/Crum Date: 4/. .!5
Estimated Cost of Project $
For Department Use Only ;
Building Base Fees
Building Base
Plan Check Review
Land Use Review $234.00
Septic Review $86.00
Potable Water -
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt # Date: Cash/Check/CC:
0 0
�� �N �a DEPARTMENT OF COMMUNITY DE I ') a t n M £
', 621 Sheridan Street,Port Townsend,l\%_1 98368 ,
tel 360.3'9.4450 11'a_e:360.3'9.44.51 I�:
tel 60. 799 &ft rim v- 'c&,, nit'deselcaprWent n�'� MAY - 5 2015
l -mail'dcd(ii co iettetson.�ca.us
•"y�fifN�i�O 7(iu, : �; :iilf ibji
nE 0Mi/UNITY DEVELOPMENT
STORMWATER CALCULATION WORKSHE >:--
MLA# •-t,`(,J4 DO PROTECT/APPLICAM NAME: ' 134 [ 1lotth 4'1 f
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 10.63 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 463,042 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 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 21/2 acres or more of
native vegetation to pasture?
Driveway, parking, roads,etc. sq/ft
Circle: Yes No
Lawn, landscaping, etc. sq/ft
Other compacted surface,etc. /� sq/ft Indicate Total Volumes of Proposed:
Total Land Disturbance V sq/ft Cut 0 Fill 0 (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 cal°worksheet—REV 10/20/2014 1
• •
STORMWATER CALULATIONS—IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) sq/ft Structures(all roof area) 14,344 sqlft
Sidewalks sq/ft Sidewalks 2,303 sq/ft
•
Patios sq/ft Patios 0 sq/ft
Solid Decks sq/ft Solid Decks 0 sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking, roads, etc sq/ft Driveway, parking, roads, etc 102,339 sq/ft
Other 28 sq/ft Other 5,200 sq/ft
Total New 28 sq/ft Total Existing 124,146 sq/ft
TOTAL NEW+TOTAL EXISTING` 124,174 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: 27
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 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.
f !) /
Pt{da (c' /� 1-) • I/ 17.
3
(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE 115EpNLY
SMALL MEDIUM REDEVELOPMENT Stormwater Site Plan: Yes No
stormwater talc worksheet-REV.10202014
2
• DRS •
BLD15-00119
BUILDING PERMIT APPLICATION Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD15-00119 Received Date: 4/9/2015
SITE ADDRESS: 63 FOUR CORNERS RD
PORT TOWNSEND, 98368
OWNER: JEFFERSON TRANSIT PHONE: 360-385-4777
1615WSIMSWAY
PORT TOWNSEND WA 98368-3090
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001332009 Section: 33 Township: 30 N Range: 1Vt
CONTRACTOR: PEASE CONSTRUCTION • PHONE: 253-584-6606
PO BOX 98046
LAKEWOOD WA 98496
Contractor's License PEASECI1190A Expires 9/1/2015
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION 35 FT SELF-SUPPORTING RADIO COMMUNICATION TOWER FOR
JEFFERSON TRANSIT
TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL:
TYPE OF IMP MEC MAIN: INDUSTRIAL:
VALUATION 6,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2012 HEAT BASE: 'HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK. BANK HEIGHT:
SEWAGE DISPOSAL: NUMBER OF EMPLOYEES:
WATER SYSTEM:
BATHROOMS:
Exist:
Prop:
Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $0.00 SRE 04/09/15
Plan Check $0.00 SRE 04/09/15
Total: $0.00
\\tidemark\data\forms\F_BLD_App_Bld.rpt 4/9/2015
• •
ON
�,�5 co� DEPARTMENT OF COMMUNITY DEVELOPMENT
K 621 Sheridan Street,Port'1 ownsend,W.1 95368
U
� 1eL 360.3.'9.44>0 j Fax:WI 3'9.4451
1eh:u��w.co.jcffcr.on.wa.usi ,,t inw t develnpmtnt
I:-mail dcd@co.iefferson.waus
PERMIT APPLICATION I APR - 9 2015
Steps in the Permit Process: " 'h_______ J
-Review application checklist to ensure all information is completed prior to submitting ap x lication. JEFFERSCiv COUNTY
-Make sure septic has been applied for and water availability has been proven. _ DEPT.OF COMMUNITY DEVELOPMENT
-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: 001332009
Site Address and/or Directions to Property:63 Four Corners Road
Port Townsend, WA 98368
Access (name of street(s)) from which access will be gained: Four Corners Road
The site is located on the northeast corner of Four Corners and State Route 20
Present use of property: vacant land
Description of Work(include proposed uses):
The project is to build a 35-ft self- supporting radio communication tower for Jefferson Transit Authority
on the west side of the Maintenance, Operation and Administration Building. This is in association with
the new Maintenance, Operations and Administration Center (BLD14-00004) and MLA13-100.
Wastewater-Sewage Disposal
This property is served by Port Townsend of Port Ludlow sewer system? YES NO 1
If not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
_ pf Septic Septic Permit#: SEP14-00002
_ 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: Not complete yet 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 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 a'p lication. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County
email hie., County email is not blocked or sent to "junk mail').
Applicant/Property Owner Information
Property Owner:
Name: Jefferson Transit Authority- Tammi Rubert, General Manager
Address: 1615 W. Sims Way Port Townsend, WA 98368
Phone#: 360-385-4777 ext. 107 E-mail Address: trubert@jeffersontransit.com
Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature:'-y — C �ir Date: /- /j-i1:3--
Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures.
Applicant Authorized Agent/Representative(it other than owner)
Name: Samantha Trone, P.E.
Address: 250 Madison Street, Suite 2R, Port Townsend, WA 98368
Phone#: 360-344-4605 E-mail Address: strove @cityofpt.us
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Architect Surveyor Contractor I Consultant
Name: Pease Construction
Address: P.O. Box 98046 Lakewood, WA 98496
Phone#: 253-606-0506 E-mail Address: tom @peaseinc.com
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Architect Surveyor Contractor Consultant
Name:
Address:
Phone#: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant
Name:
Address:
Phone#: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant
Name:
Address:
Phone#: E-mail Address:
Attach additional pages if necessary
Builders Statement
The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed
contractors and that they will be assuming the responsibs of the Gene9I Contractor for the proposed project.
Si nature: 2,,x.. j Print Name: Date: / / i5—
• •
,e-S° r.0 DEPARTMENT OF COMMUNITY DEVELO • • v;R,,; o�l,NO 3��
621 Sheridan Srreet Port'1'ownscnd, \'19536$
W id 360.3'•9,4x50 j Poe:360.3?9.-0x{511X":1
rdil"?
Web:ax�wv,,,cn.jefter;;tin.w,i.uslcAnnumniivdcvdi)nment p`O� Cj �d I�
C\E-mail:dcd(t.co.tefferson.wa.us l�
ii IN° STORMWATER CALCULATION WORKSHE i
J�MLA# " t19 100 PROJECT/APPLICANT NAME; •
(} 1/��"
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 Pia n, if
required.
PARCEL SIZE (LE.,SITE)
Size of parcel 10.63 acres An acre contains 43,560 square feet. Multiply the acreage by this figure.
Size of parcel in square feet 463,042 sq/ft 1
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 sq/t 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'/:acres or more of
native vegetation to pasture?
Driveway,parking, roads,etc. sq/ft
Circle: Yes No
Lawn,landscaping, etc. sq/ft
Other compacted surface,etc. sq/ft Indicate Total Volumes of Proposed:
J�
Total Land Disturbance V sq/ft Cut 0 Fill ° _ (culyd)
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 10/20/2014 1
•
STORMWATER CALULATIONS—IMPERVIOUS SURFACE
NEW EXISTING
Structures(all roof area) sq/ft Structures(all roof area) 14,304 sq/ft
Sidewalks sq/ft Sidewalks 2,303 sq/ft
Patios sq/ft Patios 0 sq/ft
Solid Decks sq/ft Solid Decks 0 sq/ft
(without infiltration below) (without infiltration below)
Driveway, parking,roads,etc sq/ft Driveway, parking, roads, etc 102,339 sq/ft
Other 28 sq/ft Other 5,200 sq/ft
Total New 28 sq/ft Total Existing 124,146 sq/ft
TOTAL NEW+ TOTAL EXISTING* 124,174 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: 27 %
Does the site have 35%or more of existing impervious surface? Circle: Yes No 19
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 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.
/2 r
.
(LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE)
FOR OFFICE USE ONLY
SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No Ili
stormwater talc worksheet—REV.10/20/2014
0 INVOICE te: 4/9/2015
Soy I oice ID: DCD15BLD15-00119
�v co JEFFERSON COUNTY
. <a DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street 1 Port Townsend, WA 98368
360-379-4450 I email: dcd @co.jefferson.wa.us
��stirNC�o� www.co.jefferson.wa.us/commdevelopment
- - Date Due:
BILLING ADDRESS: 5/9/2015
JEFFERSON TRANSIT
1615 W SIMS WAY
PORT TOWNSEND WA 98368-3090
Scanning Fee 19.50
Consistency Review 234.00
REMIT TO: Permit 113.00
Jefferson County DCD Plan Check 73.45
621 Sheridan St. EH SEP/Commercial Rev 258.00
Port Townsend, WA 98368
Total Amount Due: $697.95
Please return the above portion with your payment
Permit Number: BLD15-00119 Scanning Fee 19.50
Consistency Review 234.00
Permit 113.00
Plan Check 73.45
EH SEP/Commercial Rev 258.00
Total Amount Due: $697.95
Payment is accepted by cash, check, debit or credit card (Visa, Mastercard, Discover, American
Express)
To pay by credit card, go to www.co.jefferson.wa.us/commdevelopment, and click on the "Online
Credit Card & echeck Payments" link on the left side of the page. (questions: call 360-379-4450)
. 0
4�� °G DEPARTMENT OF COMMUNITY DEVELOPMENT
.t�, � 621 Sheridan bile,d,Pnrt"1ownscnd,1X';1 98368
+ �� �;t� Ld:36t)3i9.-04511 : Pax: 30.170.4451
\'Ucb WWV.eo,jeff lSOILWRAF/c xm,munttrdcvclopmern- -- —
F;mntl dcJ�(%CUietfcnoii.0 a.is I� Vim_ J ] 0 �°1 fL 1`�,,
PERMIT APPLICATION APR - 9 �, f
Steps in the Permit Process: JEFEERSON COUNTY _I
-Review application checklist to ensure all information is completed prior to submitting app icatiIPpr OF COMMUNiTY DEVELOPMENT
-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: 001332009
Site Address and/or Directions to Property:63 Four Corners Road
Port Townsend, WA 98368
Access(name of street(s)) from which access will be gained: Four Corners Road
The site is located on the northeast corner of Four Corners and State Route 20
Present use of property: vacant land
Description of Work(include proposed uses):
The project is to build a 35-ft self- supporting radio communication tower for Jefferson Transit Authority
on the west side of the Maintenance, Operation and Administration Building. This is in association with
the new Maintenance, Operations and Administration Center (BLD14-00004) and MLA13-100.
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#: SEP14-00002
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: Not complete yet Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title,which may impact the property:
None
1
•
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 mad")
Applicant/Property Owner Information
Property Owner:
Name: Jefferson Transit Authority - Tammi Rubert, General Manager
Address: 1615 W. Sims Way Port Townsend, WA 98368
Phone#: 360-385-4777 ext. 107 E-mail Address: trubert@jeffersontransit.com
Please contact Authorized Agent/Representative with project info. (select only one).
— —
Property Owner signature:'. Date: I, /�-i4-)"--
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: Samantha Trone, P.E.
Address: 250 Madison Street, Suite 2R, Port Townsend, WA 98368
Phone#: 360-344-4605 E-mail Address: strone @cityofpt.us
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor ✓ Consultant
Name: Pease Construction
Address: P.O. Box 98046 Lakewood, WA 98496
Phone#: 253-606-0506 E-mail Address: tom @peaseinc.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:
Attach additional pages if necessary
Builders Statement
The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed
contractors and that they will be assuming the responsibilit of the Gene I Contractor for the proposed project.
Print Name: //2„._,.„ 0-1264e—h- Date: /.
c,ON co DEPARtENT OF COMMUNITY DE/PLOP NT
G 621 Sheridan Street,Port Townsend,WA 98368
Tel:360.379.4430 Fax:360.379.4451 P
'-C Web:www.co.iefferson.wa.us/communitvdevelo mcnt
E-mail:dcd a)co.jefferson.wa.us r I
*Isee 9 2015 1SNINOO$ SUPPLEMENTAL APPLICATION APR 201
RESIDENTIAL OR COMMERCIAL BLDG P :RIVRT 1EFF R orvco
For Department Use Only Receipt#: f Da'Ill,l�Yr� F�pMENT
Related Application#s: Payment#:
Site Information
Owner Name: 'f:I6.s4 /,W„ a Lt,,teifw Assessor Tax Parcel#: 001 - 332-aO
Type of Building
New X Replacement Relocated
Addition Repair Demolition
'A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed,Building/Project
Number of floors .3- #new bedrooms existing total bed
#new bathrooms existing total bath
Heat Source
Select all that apply:
Electric Heating Oil Wood Propane
Enter the square footage (sq/ft)that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft
Residential/Commercial Main Floor 2
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): $ to)WO
List existing buildings on property (i.e.•se, garage, accessory dwelling unit, shedfin, mobile home,other):
All Existing Buildings on Property Use
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, her or its 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.
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.
•Signature: �� Print Name: h� Je4.L L 4- Date: 174"c2,`5
Estimated Cost of Project $
For Department Use Only _
Building Base Fees
Building Base
Plan Check Review
Land Use Review $234.00
Septic Review $86.00
Potable Water
Technology/Scan $19.50
State Fee $4.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Road Approach
Total Fees
Receipt# Date: Cash/Check/CC: