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HomeMy WebLinkAboutBLD2015-00118 - 01 PERMIT APPLICATION 0 • BLD15-00118 BUILDING PERMIT APPLICATION Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00118 Received Date: 4/9/2015 SITE ADDRESS: 343 RIDGEVIEW DR PORT TOWNSEND, 98368 OWNER: DAN VEENSTRA PHONE: 360-316-1572 TONI VEENSTRA 343 RIDGEVIEW DR PORT TOWNSEND WA 98368 SUBDIVISION: Block: Lot: PARCEL NUMBER: 001342016 Section: 34 Township: 30 N Range: 1V\ CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr DETACHED GARAGE - NO WATER/ NO PLUMBING - NEW OWNER PERMITTING GARAGE BUILT BY PREVIOUS OWNER TYPE OF WORK GAR SQUARE FOOTAGE: &pCi 'C3D ' TYPE OF IMP NEW MAIN: VALUATION 35,460.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: 2 OCCUPANCY: OTHER: CONST TYPE: SHORELINE: GARAGE: 1,227 SETBACK: CONST TYPE: DECK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $443.00 SRE 04/08/15 154286 APPROVED Plan Check $287.95 SRE 04/08/15 154286 State Building Code $4.50 SRE 04/08/15 154286 APR 2 L 2015 Total: $735.45 Jefferson County DCD \\tidemark\data\forms\F_BLD_App_Bld.rpt 4/9/2015 I J. f ��o c DEPARTMENT OF COMMUNITY DEVELOPM - 'cc 06. 621 Sheridan Street,Port Io«nsend,A\A 98368 I —7 NY!! Tel 360.3-9.4430 Fax: 360.3-9.4451 �-�� ti \Veb:\v\v .co.lefferson.wa.us'communm development E-mail:dcd(a co.jefferson.wa.us � APR — 2015 �SHI NO�o SUPPLEMENTAL APPLICATION jai; RESIDENTIAL OR COMMERCIAL BLDG PERMIT ,'r1IIYDLlifIiCr ENT For Department Use Only Receipt#: Date: Related Application Us: Payment If: Site Information Owner Name: DA Rl_sr(LA Assessor Tax Parcel #: O6 ,3 4-20/6 Type of Building New G/�RAG Replacement Relocated Addi ion Repair Demolition * *A separate permit is required Select One: C"Sngle Family Residence Modular Other list Proposed Building/Project Number of floors If new bedrooms -e--" existing ,_,05:(._ total bed -e- # new bathrooms ,�.._ existing ,... -- total bath _—. Heat Source Select all that y: 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 / nheated g z..5" .,j Attached Garage - heated /unheated Garage 2nd fl unfinhed storage 4'0 Z 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): $ $ S I A17k At 1 • • List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use /4O U3G �Esli c& G Aft,A C GAtL4C-1 / SI-6 R.#(F Builders S a m t to n e The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed contractors and th ,t ey r .e assuming the responsibility of the General ontractor for the proposed project. 1/.3..-- Signature: ♦ ,� Print Name: � �iC,l >��uS� Date: Lk/6 By signing this app cati I n form,the owner/agent attests that the information provided herein,and in any attachments, is true and correct to the bes of h or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respec o h app icat packet may result in making any issued permit null and void. Signature: ti _, .-- Print Name: h ft,/u Y� 4...) trksi4 Date: t' " el For Department Use Only Building Permit Fees Building Base Plan Check Review Land Use Review $234.00 Septic Review $80.00 Potable Water $109.00 Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt # Date: Cash/Check/CC: • e ,. times°`� -o6s DEPARTMENT OF COMMUNITY DEVELOPMENT 4. a 621 Sheridan s•rrerr,Port 1∎nc-nsr:i \\.\98 368 �� ^C Tel:360.3'9.443+) ■ fax:360.3-9.4451 Web:www.co.iettL_so.;.cca.0■.i L(nnm mtrdevelopment :: • E-mail:dcd a co.irtfer n.cc-. us 9SHI Norco PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# Site Information Assessor Tax Parcel Number: 60 i 39- 2_01 Site Address and/or Directions to Property: 3 4 t fl(a� i W Pop.7--Ye al e, C E a.6 LAJ.- 18.z Access (name f street(s)) from which access will be gained: k..tI --eft b /,P ' rte... Present use of property: if , . .. Description of Work(include proposed uses): pF-1(2 ktr T--- 1i j r t.(f 7 GAR-ACCIL Wastewater-Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES _ _ NO If not served by sewer identified above, identify type of septic system below: Type of Sewa. -m Serving Property: _ Septic f-L 5 Septic Permit#: 5E-__ • / . -- O2-2- _. - un ty Septic Name of System: R 1P:,GFJ,w SKo2r-- P.-AT–L©T 2Case#: 77 ___z.7_1-1- Are other residences connected to the septic system? 1,)d Additions or repairs to sewage system: ki d Is it a complete or partial system installation: Com llet e — Partial _ — Has a reserve drainfield been designated? No Date of Last Operations& Maintenance check: QG3/02.J( Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: i /`■i U N E__ 1---7\ i, f \ 1` 1 _ !I' i APR - 82015 ` ._ 1DEFERSON COUNTY DEPT Of COMMUNITY DEVELOPMENT • • • 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: Name: D A kt .l- T N t `/E,a tai `1"IR A Address: 34743 P, DGEVI --W DRNE) Pc, rTO 'r s iiDf t et 834 8 Phone#: 36(} s 1 c E-mail).- -7 Address: -re c ATE s op,i MEgrO Poi-M&/E.,. — — Please contac uthori d Agent/Representative with project info. (select only one).Property Owner Signature: Date: g- /8/)Note: for projects with multiple owners, ach a separate sheet with each owner(s)information and signatures Applicant: Authorized Agent/Representative(If other than owner) Name: Address: S/-ME-- -t. 4 goiJ F--- Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: 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. I further agree to tha .11 activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal,*ate and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its employees, represen tives • agents for the sole purpose of application review and any required later inspections. Applicant may request notice of he • i II ntent s ntent to enter upon the property for visits related to this pplication and subsequent permit issuance. I #Signature: _, Print Name: ILOJ 4 Date: 4/5/i 5--- Bernt&tcsen Excavating,Inc. 2281 Hastings Ave. West 360-385-3602 Port Townsend,WA 98368 PROPERTY INFORMATION EC Ell o f Location:343 RIDGEVIEW DR Tax ID:001342016 Maya To: RICHARDM S APR - 8 343 RIDGEVIEW 2015 Use: PORT TOWNSEND 111fA 983682580 U CNVELOPMENT W ?EPI OF COMlt4UJEFFERS0INITY OUDE Owner RICHARD MEADOWS ON ID:SOM99-00224 Fold ONSITE SEWAGE SYSTEM INSPECTION REPORT Fold Here Inspected:06102/2014 - Inspection Type:ROUTINE - Correction Status:All corrections made Here Company: Work Performed By: Submitted 06/11/2014 by: Bemt Ericsen Excavating,Inc. Tim Thomas Tim Thomas N. This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development. COMMENTS&GENERAL INSPECTION NOTES Oeficencies Were Noted:Corrections were made to resolve the deficiencies, Drainfield area needs to be mowed to better locate inspection ports. GENERAL SITE&SYSTEM CONDITIONS The General Site and System Conditions were: Fully Inspected All Components accessible for maintenance,secure and in good condition: YES Surfacing effluent from any component(including mound seepage): NO Components appear to be watertight-no visual leaks: YES Improper encroachment(roads,buildings,etc.)onto component(s): NO Component settling problems observed: NO Abnormal ponding present for one or more of the disposal components: NO Subsurface components adequately covered YES Owner compliance issues noted NO Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: YES Occupant compliance problem(occupant not operating the system properly). If YES,describe in notes: - _ NO If deficiencies were identified on last inspection were they corrected before or during this inspection? N/A (If NO,describe in notes,NA=no deficiencies on last report): OSS Components,structures and appurtenances located per as-built/record drawing(If NO,describe YES -� in notes). If no as-built exists or changes made,state NO and provide record to Health Dept Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If YES, NO describe in notes): The house/structure was vacant or used infrequently,assessment of the drainfield was not possible. NO Is the SEP case in a finaled/completed status?(if NO explain in comments) YES- ONSITE SEWAGE SYSTEM INSPECTION DETAIL 'anel:Control-4 Pump This component was: Fully Inspected Panel functioning(including alarm): YES Pump 1:on minutes(override in parentheses-if present): 00:00:41 Pump 1:off hours(override in parentheses-if present): 03:00:00 Pump 1:gallons per dose(override in parentheses-if present): Pump 1:ETM hours(override in parentheses-if present): 10352:00 Pump 1:Cycle Count(override in parentheses-if present): 15252(1311) This report indicates certain charaderistics of the onsite sewage system at the time of visit.In no way is this report a guarantee of operahon or future performance. Report(D:380553 View inspection reports online at www.onlinerme.com Page 1 of 2 • ����°N coG� JEFFERSON COUNTY t,j ''::, �- DEPARTMENT OF COMMUNITY DEVELOPMENT 1 - --r-l) L V E h _________ _ . . 621 Sheridan Street • Port Townsend • Washington 98368.qs xsO 360/379 4450 • 360/379 4451 Fax I APR 2O 5 ING http://www.co.jefferson.wa.us/commdevelopmenti I Ufi J JEFFERSON COUNTY Stormwater Calculation Worksheet Li_ DEPT.OFCOM144UNITYDEVELOPMENT MLA# 0 d I l 2-0 I Ip PROJECT/APPLICANT NAME: D A l ^¢- low Y EE'�iv sr R i-T 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 2 2,. acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 1 0 2d, 4N D 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 //r 50 sq/ft native vegetation to lawn or landscaped areas? t6Drainfield,septic tank, etc. 50 sq/ft Circle: Yes No Well, utilities, etc. '7)'-" sq/ft Does the project convert 2%acres or more of native vegetation to pasture? Driveway, parking, roads, etc. C)Q sq/ft — Circle: Yes No Lawn, landscaping, etc. 8 f-7 Z 0 sq/ft Other compacted surface, etc. -1ST" sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance I 14 1 -b 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) Z sq/ft Structures(all roof area) 1 366 sq/ft Sidewalks sq/ft Sidewalks =--- sq/ft Patios sq/ft Patios 64•3 0 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 2 674 C sq/ft Other sq/ft Other sq/ft Total New e _sq/ft Total Existing sq/ft TOTAL NEW+TOTAL EXISTING* T-7 sq/ft *This amount will be used BY STAFF to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT /�/, dd� Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: LTe 1•+ ova 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 est of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the ected : operty. (LANDON, ER,t: •U ORI: S r •• ATI r • a (DA E) FOR OFFICE USE ONLY SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No stormwa!e,calc worksheet Rev 9-9-2010—REV 9/9/2015 . D QO •BUILDING PERMIT APPLICATION Review Type: Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00118 Received Date: 4/9/2015 SITE ADDRESS: 343 RIDGEVIEW DR PORT TOWNSEND, 98368 OWNER: DAN VEENSTRA PHONE: 360-316-1572 TONI VEENSTRA 343 RIDGEVIEW DR PORT TOWNSEND WA 98368 SUBDIVISION: Block: Lot: PARCEL NUMBER: 001342016 Section: 34 Township: 30 N Range: 1V1 CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr DETACHED GARAGE - NO WATER / NO PLUMBING - NEW OWNER PERMITTING GARAGE BUILT BY PREVIOUS OWNER TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 35,460.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: 2 OCCUPANCY: OTHER: CONST TYPE: GARAGE: 1,227 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $443.00 SRE 04/08/15 154286 Plan Check $287.95 SRE 04/08/15 154286 State Building Code $4.50 SRE 04/08/15 154286 Total: $735.45 \\tidemark\data\forms\F_B LD_App_B ld.rpt 4/9/2015 • y . • DEPARTMENT OF COMMUNITY DEVELOPMENT ON c O(„ 621 Sheridan Street,Port Townsend,\X-_-1 98368 W + Tel:360.3 79.-140 Fax:360.379. 451 7-G \Ceb:www.co.ietterson.\a.us/commutitydevelooment E-mail:dcd6t:co.iefferson-wa.us SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt#: Date: Related Application#s: Payment#: Site Information Owner Name: - N j Assessor Tax Parcel#: Q6 �3 -20/6 Type of Building New GAR_AGa, Replacement Relocated Addition Repair Demolition *A separate permit is required Select One: 'Single Family Residence f, Modular Other list Proposed Building/Project Number of floors Z. # new bedrooms -z-- existing total bed #new bathrooms existing total bath Heat Source Select all that y: 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 g S� Attached Garage- heated/unheated Garage 2nd fl unfinished storage 14-0 Z " `k 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): $ $ S/- A77*e'4 mr-pr- • 0 . List existing buildings on property(i.e. house, garage,accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use CS P en w fA&4( / 3i I Builders Statemen The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed contractors .nd th..t hey 1"se assuming the responsibility of the General Contractor for the proposed project. Signature: A AlibIL Print Name_b /U51 Date: y"` S ts By signing this app cati n form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of h s or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect o h app icat", packet may result in making any issued permit null and void. 4._ Signature: ��� L Print Name: l �- ±<' Date: La; /, r--- For Department Use Only Building Permit Fees Building Base Plan Check Review Land Use Review $234.00 Septic Review $80.00 Potable Water $109.00 Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt 44 Date: Cash/Check/CC: r . • ��sO cob DEPARTMENT OF COMMUNITY DEVELOPMENT �� ✓i--� 621 'hencian�rrecr_Port 1 vt nsend.AV._A 98368 LT./ C Tc::360.3 9.-1430 Fax 361.3-9.4351 Web:\\-va°w.co.iettcrsor wa.us cmmn ,dmi..kv-elopment E-mail:dcdU1{O.lertCr. n.R-a.ns •�,y Ii N GAG PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# Site Information Assessor Tax Parcel Number: 60 I 3#.2O1 G Site Address and/or Directions to Property: 3 ii 3 P. 1 p&adi Co-s 0 (,Z,,1 J,E Pc*.�--Te wmS 6/ 7'tiLIA ' &3‘=„z3 Access (name f street(s)) from which access will be gained: L(( r, E--bli 1 2H VE Present use of property: kiftl, 4„4 f.L. Description of Work(include proposed uses): , Jg . -1--- vki r &.L4I r G#VAS 1 1 Wastewater-Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO If not served by sewer identified above, identify type of septic system below: Type of Sewa:--,. .-m Serving Property: Septic Septic Permit#: $E p II -- 02-2-1- _, - unity Septic Name of System: kin c, (6,,, SNon r PLAT—LOT 2Case#: 77_7_2_11- Are other residences connected to the septic system? .j Additions or repairs to sewage system: Is it a complete or partial system installation: Complete Partial Has a reserve drainfield been designated? 40 No Date of Last Operations & Maintenance check: 0le/2_/(i't Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: /QOA/E -_ 1 \\J E T■ J( 1 APR - 82015 - i J) JEFFERSON COUNTY ,PFPT.OF COMMUNITY DEVELOPMENT • • 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: Name: D A \/E,aNsTRA Address: 3 LI-3 P i DGEVs -W QR1V1�1 PokT1OwMSEMV1 kVA '8368 Phone#: 360 31 6—l S 7 2., E-mail Address: TECATE SOM ME1e„Ca 1-40T mkt&. Please contac uthori d Agent/Representative with project info. (select only one). 0 Property Owner Signature: Date: I' /8/i -- Note: For projects with multiple owners, ach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative Of other than owner) Name: Address: ;1- Rot f- IL( 4 go J Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone It E-mail Address: 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. I further agree to tha all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, •tate and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its employees, represen .tives • agents for the sole purpose of application review and any required later inspections. Applicant may request notice of he faun s ntent to enter upon the property for visits related to this pplication and subsequent permit issuance. Signature: 1 0 ____ Print Name: D A OJ larlticrIZA Date: _+ • 4�g�oN coc, JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT E!.! EI: 98368• Port Tosend Washington 98368 R`s$I'�O�O ax m mdevelopment/ APR - 8 2015 St ormwater Calculation Worksheet JEFFERSON COUNTY R DFPTOFCOMMUNITYDEVELOPMF • MLA## 00 l3 Li- z© I G PROJECT/APPLICANT NAME: D/�� * lap VEX-NI,ST R 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 2 Y2... acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet / 0� q0O 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: 2 ( � Does the project convert%acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? (6 n Drainfield, septic tank, etc. (6 SO sq/ft Circle: Yes No Well, utilities, etc. sq/ft Does the project convert 2 '/2 acres or more of �Q©0 native vegetation to pasture? Driveway, parking, roads, etc. sq/ft — Circle: Yes No Lawn, landscaping, etc. 8 7 2 0 sq/ft Other compacted surface, etc. sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 114'f 5j-C b 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) Z sq/ft Structures (all roof area) 1360 sq/ft Sidewalks sq/ft Sidewalks -- sq/ft Patios sq/ft Patios C 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 2 co sq/ft Other Other sq/ft Total New U ��_sq/ft Total Existing 3,1 sq/ft TOTAL NEW+ TOTAL EXISTING* 1+7 85' sq/ft *This amount will be used BY STAFF to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT /� D 4 ivide the total existing impervious surface above by the size of the parcel and convert to a percentage: 140 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 q proposal is considered p p ed new development and the attached Figure 1 should be used, At this juncture, the applicant should refer 1 pp 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 kest of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the ected • o•erty. 1-3/4.) ireu_srm (LANDO ERWUVORI!l.V-•• AT _ .• • (DA E) FOR OFFICE USE ONLY SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No stormwater calc worksheet Rev 9-9-2010—REV 9/912010