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Home My WebLink AboutBLD2021-00042 - 10 COMMUNICATIONSAccess Connection Permit Managed Access Highways Only Not for use within an Incorporated City or Town Name and Address of Applicant Permit Number ACP- State Route Mile Post Left Right Region County Property Address (If different from above) Joint Use Connection: Yes No Primary Tax Parcel Number Email Telephone Additional Tax Parcel Numbers (if applicable) Project Name (If Applicable) Lot # Gov. Lot # Average Weekday Vehicle Trip Ends (AWDVTE) not to exceed: Approach width not to exceed feet wide Public Land Survey System (PLSS) 1/4 of the 1/4 of Section Township N,Range E W Permit Category 1 - Minimum Connection 2 - Minor Connection 3 - Major Connection 4 - Temporary Connection Permit Type Conforming Permit Non-Conforming Permit Variance Permit &XUUHQW0DQDJHG$FFHVV+LJKZD\&ODVVL¿FDWLRQ Class 1 - 1320’ Minimum Approach Spacing Class 2 - 660’ Minimum Approach Spacing Class 3 - 330’ Minimum Approach Spacing Class 4 - 250’ Minimum Approach Spacing Class 5 - 125’ Minimum Approach Spacing This Access Connection Permit serves: The Applicant hereinafter will be referred to as the “Permit Holder,” and the Washington State Department of Transportation hereinafter will be referred to as “WSDOT.” WSDOT will allow the Permit Holder to construct, upgrade, use, and/or maintain this access connection provided the Permit Holder accepts all the terms, provisions, and exhibits attached hereto and by this reference made a part of this permit. This permit is assigned to the parcel(s) served by the access connection, and shall remain with the parcel(s) served by this permit regardless of any change in ownership of the parcel(s). Exhibit A: Special Provisions for Access Connections Exhibit B: Right of Way Sheet or Vicinity Map This permit shall be void unless the work authorized by the permit is started within 90 days of issuance and completed within 120 days of issuance, unless otherwise agreed to in writing by WSDOT or if an extended completion date is listed here by WSDOT: No construction work is allowed without a pre-construction conference with WSDOT. By signing below the Permit Holder accepts the terms, provisions, and exhibits attached to and made a part of this permit. PERMIT HOLDER Print Name Print Title Signature Date WSDOT Print Name Print Title Signature . Date DOT Form 224-005 Revised 04/2020 Page 1 re 60687John/Christie LaPlume 2811 Evelyn Ct Vienna, VA 22180 20 4.8 Olympic Clallam 901054007 No established address laplumece@gmail.com 703-966-8884 100 30 sw SE 5 29 1 Single Family Residence Exhibit C – Traffic Control Plan(s) Exhibit D – Driveway Design Template(s) 9/1/2021 John/Christie LaPlume Nate Bergeman Owner M&O Asst. Supt. 4/8/2021 General Provisions 1. INDEMNIFICATION The Permit Holder, its heirs, successors and assigns, agrees to indemnify, defend, and hold harmless the State of :DVKLQJWRQDQGLWVRႈFHUVHPSOR\HHVDQGDJHQWVIURPDOOFODLPVGHPDQGVGDPDJHVERWKWRSHUVRQVDQGRU SURSHUW\H[SHQVHVUHJXODWRU\¿QHVDQGRUVXLWVWKDWDULVHRXWRIRUDUHLQFLGHQWWRDQ\DFWVRURPLVVLRQVE\WKH Permit Holder, its agents, contractors, tenants, invitees, licensees, and/or employees, in the use of the state highway right-of-way as authorized by the terms of this Permit, and/or (2) are caused by the breach of any of the conditions of this Permit by the Permit Holder, its agents, contractors, tenants, invitees, licensees, and/or employees. The Permit Holder, its heirs successors and assigns, shall not be required to indemnify, defend, or hold harmless the State of Washington and LWVRႈFHUVHPSOR\HHVDQGRUDJHQWVLIWKHFODLPVXLWRUDFWLRQIRUGDPDJHVERWKWRSHUVRQVDQGRUSURSHUW\LVFDXVHG E\WKHVROHDFWVRURPLVVLRQVRIWKH6WDWHRI:DVKLQJWRQLWVRႈFHUVHPSOR\HHVDQGRUDJHQWVSURYLGHGWKDWLIVXFK FODLPVVXLWVRUDFWLRQVUHVXOWIURPWKHFRQFXUUHQWQHJOLJHQFHRIDWKH6WDWHRI:DVKLQJWRQLWVRႈFHUVHPSOR\HHVDQG or agents and (b) the Permit Holder, its agents, contractors, tenants, invitees, licensees, and/or employees, or involves those actions covered by RCW 4.24.115, the indemnity provisions provided herein shall be valid and enforceable only to the extent of the acts or omissions of the Permit Holder, its agents, contractors, tenants, invitees, licensees, and/or employees. The Permit Holder agrees that its obligations under this section extend to any claim, demand and/or cause of action brought by, or on behalf of, any of its employees or agents while performing construction, operation and/or maintenance work authorized by this permit. For this purpose, THE PERMIT HOLDER BY MUTUAL NEGOTIATION HEREBY WAIVES WITH RESPECT TO THE STATE OF WASHINGTON ONLY, ANY IMMUNITY THAT WOULD OTHERWISE BE AVAILABLE TO IT AGAINST SUCH CLAIMS UNDER THE INDUSTRIAL INSURANCE PROVISIONS OF CHAPTER 51.12 RCW. The Permit Holder further agrees that the proper performance, safe conduct, and adequate policing and supervision RIWKHZRUNDXWKRUL]HGE\WKLVSHUPLWVKDOOQRWEHOHVVHQHGRURWKHUZLVHDႇHFWHGE\:6'27¶VDSSURYDORIWKHSODQV VSHFL¿FDWLRQVRUZRUNDXWKRUL]HGE\WKLVSHUPLWRUE\WKHSUHVHQFHDWWKHZRUNVLWHRI:6'27UHSUHVHQWDWLYHVRUE\ compliance by the Permit Holder with any requests or recommendations made by such representatives. 7KLVLQGHPQL¿FDWLRQDQGZDLYHUVKDOOVXUYLYHWKHWHUPLQDWLRQRIWKLV3HUPLW 2. REQUIRED PROPERTY RIGHTS If the parcel(s) served by this permit does not abut the state highway, the Permit Holder must provide legally recorded easements or other property rights that grant a continuous right of access between this parcel(s) and the state highway right-of-way as required by WAC 468-51-030(2). The Permit Holder shall provide copies of these documents to WSDOT before beginning any work authorized under this permit. 3. PERMIT TYPES There are three types of Access Connection Permits – Conforming, Non-Conforming, and Variance Access Connection Permits. A brief description of each of these three types of permits is as follows: • Conforming Access Connection Permits (WAC 468-51-020(4)) meet current WSDOT location, spacing, and design criteria standards at the time of the permit application submittal. • Nonconforming Access Connection Permits (WAC 468-51-100) do not meet WSDOT’s location and spacing criteria standards at the time of the permit application submittal, but denial would leave the property without reasonable access onto the public road system. Nonconforming Access Connection Permits may continue only until WSDOT determines that a Conforming Access Connection can be constructed, in such case the Nonconforming Access Connection shall be removed • Variance Access Connection Permits (WAC 468-51-105) are a special nonconforming or additional access connection permit issued for a location not normally permitted by WSDOT standards current at the time of permit application. A Variance Access Connection Permit may be issued only after an engineering study GHPRQVWUDWHVWRWKHVROHVDWLVIDFWLRQRI:6'27WKDWWKHFRQQHFWLRQZLOOQRWDGYHUVHO\DႇHFWWKHVDIHW\ PDLQWHQDQFHRURSHUDWLRQRIWKHVWDWHKLJKZD\LQDFFRUGDQFHZLWKLWVDVVLJQHGFODVVL¿FDWLRQ$9DULDQFH Access Connection Permit may only be issued for Class 2 thru Class 5 highways and may remain unless a QHZSHUPLWLVUHTXLUHGGXHWRFKDQJHVLQSURSHUW\VLWHXVHRUXQOHVV:6'27PRGL¿HVUHYRNHVRUFORVHVWKH permit pursuant to WAC 468-51-120. DOT Form 224-005 Revised 04/2020 Page 2 4. OTHER PERMITS, FRANCHISE RIGHTS, AND AGREEMENTS This permit shall not be deemed or held to be an exclusive one and shall not prohibit WSDOT from granting other permits, franchise rights, and/or agreements or from entering into other permits, franchise rights, and/or agreements of like or other nature with other public or private companies or individuals for the use of the state highway right-of-way, nor shall it SUHYHQW:6'27IURPXVLQJDQ\RILWVKLJKZD\VVWUHHWVRUSXEOLFSODFHVRUDႇHFWLWVULJKWWRIXOOVXSHUYLVLRQDQGFRQWURO over all or any part of them, none of which is hereby surrendered. 5. PERMITS FROM OTHER AGENCIES The Permit Holder shall be responsible for obtaining all necessary Federal, State, and Local Permits including, but not limited to, Washington State Department of Ecology, Washington State Department of Fish and Wildlife, Washington State Department of Natural Resources, and U.S. Army Corps of Engineers permits or other approvals required prior to beginning any of the work authorized in this permit. The Permit Holder shall defend and hold harmless the State of :DVKLQJWRQLWVRႈFHUVDQGHPSOR\HHVIRUDQ\¿QHVFRVWVRURWKHUDPRXQWVVKRXOGWKH3HUPLW+ROGHUIDLOWRREWDLQDOO required permits. 6. PERMIT HOLDER’S REPRESENTATIVE Should the Permit Holder not be present during any of the work authorized by this permit, the Permit Holder shall designate a representative that has either the legal authority to represent the Permit Holder or the authority to make decisions on behalf of the Permit Holder with respect to the work authorized by this permit. The Permit Holder, at its own expense, shall adequately police and supervise all work authorized by this permit, including but not limited to its contractor, subcontractor, agent, and others, so as not to endanger or injure any person or property. The Permit Holder or the Permit Holder’s representative shall be present during any active construction or maintenance work authorized by this permit. Failure to comply with this provision may result in WSDOT restricting any further work by the Permit Holder within the state highway right-of-way until this requirement is met. 7. PRE-CONSTRUCTION CONFERENCE 7KH3HUPLW+ROGHUVKDOOQRWVWDUWDQ\FRQVWUXFWLRQRQVWDWHKLJKZD\ULJKWRIZD\ZLWKRXW¿UVWKDYLQJDSUHFRQVWUXFWLRQ meeting which shall be attended by WSDOT, the Permit Holder or its authorized representative, and the Permit Holder’s contractor, if applicable. Unless requested otherwise by WSDOT, the preconstruction conference shall be onsite at the location of the work authorized by this permit. 8. WSDOT NOTIFICATION 7KH3HUPLW+ROGHUVKDOOQRWLI\:6'27DPLQLPXPRI¿YHZRUNLQJGD\VSULRUWRLQFOXGLQJEXWQRWOLPLWHGWRWKH SUHFRQVWUXFWLRQFRQIHUHQFHWKHEHJLQQLQJRIDQ\FRQVWUXFWLRQZRUNWKHLPSOHPHQWDWLRQRIDQ\WUDႈFFRQWUROSODQWKDW FORVHVRUUHVWULFWVDVLGHZDONSDWKZD\WUDLOKLJKZD\VKRXOGHURUWUDYHOHGODQHRIWKHVWDWHKLJKZD\VXEPLWWDORIDQHZ RUUHYLVHGWUDႈFFRQWUROSODQDQ\H[WHQVLRQRIDOORZHGZRUNLQJKRXUVRUGD\VDQGWKH¿QDOLQVSHFWLRQXSRQFRPSOHWLRQRI the construction. Working days, for the purposes of notifying WSDOT of any work or other activity as authorized by this permit, are the weekdays Monday through Friday, excluding legal holidays. 9. PERMIT DOCUMENTS ON SITE A complete copy of this permit, protected from the elements, shall be readily available any time active construction work is being performed as authorized by this permit. The permit shall be shown, upon request, to any state representative or law HQIRUFHPHQWRႈFHU)DLOXUHWRFRPSO\ZLWKWKLVSURYLVLRQPD\UHVXOWLQ:6'27UHVWULFWLQJDQ\IXUWKHUZRUNE\WKH3HUPLW Holder within the state highway right-of-way until said requirement is met. 10. TRAFFIC CONTROL PLANS 7KH3HUPLW+ROGHUVKDOOQRWLPSOHPHQWDQ\WUDႈFFRQWUROSODQV7&3RQVWDWHKLJKZD\ULJKWRIZD\ZLWKRXW:6'27¶V prior written approval. It is the Permit Holder’s responsibility to plan, conduct, and safely perform the work authorized by this permit. Should additional TCP’s be needed for the construction and/or maintenance of the work authorized by this SHUPLWWKH3HUPLW+ROGHUVKDOOVXEPLWZRUNVSHFL¿FWUDႈFFRQWUROSODQVWR:6'27IRUUHYLHZDQGZULWWHQDSSURYDO $ZLGHUDQJHRISHGHVWULDQVPLJKWEHDႇHFWHGE\WUDႈFFRQWURO]RQHVLQFOXGLQJWKH\RXQJHOGHUO\DQGSHRSOHZLWK disabilities such as hearing, visual, or mobility. Bicyclists may also be impacted. The Permit Holder shall implement DOOUHDVRQDEOHPHDQVRIWUDႈFFRQWUROQHFHVVDU\WRDGHTXDWHO\DFFRPPRGDWHWKHVHQHHGVLIWKH\FDQEHUHDVRQDEO\ expected to be encountered during the work authorized by this permit. $OOWUDႈFFRQWUROSODQVVKDOOEHLQFRPSOLDQFHZLWKWKHFXUUHQWHGLWLRQVRIWKH:DVKLQJWRQ6WDWH'HSDUWPHQWRI 7UDQVSRUWDWLRQ:6'27:RUN=RQH7UDႈF&RQWURO*XLGHOLQHVDQG)HGHUDO+LJKZD\$GPLQLVWUDWLRQDSSURYHG0DQXDORQ DOT Form 224-005 Revised 04/2020 Page 3 8QLIRUP7UDႈF&RQWURO'HYLFHV087&'IRU6WUHHWVDQG+LJKZD\V 7KH:6'27:RUN=RQH7UDႈF&RQWURO*XLGHOLQHV0PD\EHDFFHVVHGDW http://www.wsdot.wa.gov/Publications/Manuals/M54-44.htm 7KH087&'LQFOXGLQJPRGL¿FDWLRQVIRU:DVKLQJWRQ6WDWHPD\EHDFFHVVHGDW KWWSZZZZVGRWZDJRY2SHUDWLRQV7UDႈFPXWFGKWP 11. CHANGES TO TRAFFIC CONTROL PLANS :6'27UHVHUYHVWKHULJKWWRLPPHGLDWHO\PRGLI\VXVSHQGRUUHYRNHDQ\WUDႈFFRQWUROSODQRUZRUNDXWKRUL]HGXQGHU this permit, including but not limited to lane closures and shoulder closures due to unexpected conditions or other circumstances which WSDOT determines is in the best interests of the state and/or safety of the traveling public. All costs DVVRFLDWHGZLWKDPRGL¿FDWLRQVXVSHQVLRQRUUHYRFDWLRQVKDOOEHERUQHVROHO\E\WKH3HUPLW+ROGHU:6'27VKDOOLQQR way be held liable for any delays, costs, or other damages to the Permit Holder by reason of any such WSDOT action. 12. TRACKING OF MATERIAL The Permit Holder shall maintain the surface of the access connection to prevent the tracking of material onto any portion of the state highway, including the traveled lanes and shoulders of the highway. Any tracking of material onto the highway, such as mud or debris, shall be immediately cleaned up by the Permit Holder in accordance with RCW 46.61.655. Should the Permit Holder fail to immediately correct or clean up material tracked onto the state highway after receiving written notice from WSDOT, WSDOT reserves the right to perform the necessary work to preserve the state highway right-of-way or for the protection of the traveling public or pedestrians. If WSDOT performs the work as provided herein, the Permit Holder agrees to make payment to WSDOT within thirty (30) calendar days of the date of WSDOT’s detailed invoice. If WSDOT chooses not to perform the work, WSDOT may initiate an action to revoke this permit as provided as provided by WAC 468-51.120. 13. EROSION AND SEDIMENTATION CONTROL 7KH3HUPLW+ROGHUVKDOOFRPSO\ZLWKWKH:DVKLQJWRQ6WDWH'HSDUWPHQWRI7UDQVSRUWDWLRQ+LJKZD\5XQRႇ0DQXDO+50 and implement Best Management Practices (BMP’s) to reduce erosion, trap sediment, and ensure that sediment-laden water does not leave the work site. The HRM establishes minimum requirements and provides uniform technical guidance for avoiding, minimizing, and/or mitigating potential water resource impacts. All water discharges to or from the state highway right-of-way due to the work activities authorized by this permit shall conform to all applicable federal, state, and local water quality regulations. 7KH:DVKLQJWRQ6WDWH'HSDUWPHQWRI7UDQVSRUWDWLRQ+LJKZD\5XQRႇ0DQXDO0PD\EHDFFHVVHGDWhttp://www. wsdot.wa.gov/Publications/Manuals/M31-16.htm 14. CULTURAL RESOURCES If any archaeological or historical resources are revealed due to the work authorized under this permit, the Permit Holder shall immediately stop work and notify WSDOT’s representative and retain a United States Government Secretary of WKH,QWHULRU¶VTXDOL¿HGDUFKDHRORJLVW6DLGDUFKDHRORJLVWVKDOOHYDOXDWHWKHVLWHDQGPDNHUHFRPPHQGDWLRQVWR:6'27 regarding the continuation of the work. 15. UTILITY IMPACTS All manholes, valve covers, catch basins, utility boxes, or other similar utility appurtenances impacted by the work authorized in this permit that do not require a separate WSDOT Utility Permit or Utility Franchise shall be constructed, PRGL¿HGRUUHSDLUHGWRPDWFKWKHKLJKZD\VKRXOGHUVORSHDQGLIRXWVLGHWKHKLJKZD\VKRXOGHUVKDOOPDWFKWKHDGMDFHQW WHUUDLQDVUHTXLUHGE\:6'27$Q\:6'27LQVSHFWLRQRUFRQFXUUHQFHRIWKLVZRUNVKDOOEHIRUWKHVROHEHQH¿WRI:6'27 and not for the Permit Holder or any third party. The Permit Holder shall make a timely application for any WSDOT-issued Utility Permit, Utility Franchise, or an amendment to an existing utility permit or franchise. Failure to obtain any required Utility Permit, Utility Franchise, or an amendment to an existing utility permit or franchise in a timely manner may result in WSDOT delaying the work authorize by this permit until such time that the require documents are obtained. The Permit Holder agrees on behalf of itself, its successors, assigns, tenants, invitees, licensees, contractors, agents and/or employees, that WSDOT shall in no way be held liable for any delays, costs, or other damages to the Permit Holder or its successors, assigns, contractors, tenants, invitees, licensees, employees and/or agents by reason of any action taken by WSDOT pursuant to this section. Additional guidance in accommodating utilities within state highway right-of-way may be found in the current editions of the Washington State Department of Transportation Utilities Accommodations Manual M22-86 and WSDOT Utilities Manual M22-87. DOT Form 224-005 Revised 04/2020 Page 4 The WSDOT Utilities Accommodations Manual, M22-86, may be accessed at: http://www.wsdot.wa.govPublications/ Manuals/M22-86.htm. The WSDOT Utilities Manual, M22-87, may be accessed at: http://www.wsdot.wa.gov/Publications/Manuals/M22-87.htm 16. SURVEY MONUMENTS 7KH3HUPLW+ROGHUVKDOOQRWGLVWXUEUHPRYHRUGHVWUR\DQ\H[LVWLQJVXUYH\0RQXPHQWEHIRUH¿UVWREWDLQLQJD:DVKLQJWRQ State Department of Natural Resources (DNR) permit. The Permit Holder further agrees that all WSDOT control and DOLJQPHQWPRQXPHQWVPD\QRWEHGLVWXUEHGUHPRYHGRUGHVWUR\HGXQOHVVVSHFL¿FDOO\DXWKRUL]HGE\WKLVSHUPLWRU pursuant to WSDOT’s prior written approval. Any reset survey Monument shall be set by or under the direct supervision of a Professional Land Surveyor who has an active professional license with the State of Washington. $OLVWLQJRI6XUYH\0RQXPHQWVPD\EHDFFHVVHGDW:6'27¶V*HRJUDSKLF6HUYLFHV2ႈFH:HEVLWH http://www.wsdot.wa.gov/monument/searchBroad.aspx 17. DELAY TO WSDOT WORK All work authorized by this permit shall be done in such a manner by the Permit Holder as will cause the least interference with any of WSDOT’s or it’s contractor’s work on the state highway. The Permit Holder agrees on behalf of itself, its successors, assigns, tenants, invitees, licensees, contractors, agents and employees, that WSDOT shall in no way be held liable for any delays, costs, or other claims or damages by the Permit Holder or its successors, assigns, tenants, invitees, licensees, contractors, agents and/or employees occasioned by WSDOT’s or its contractor’s work on the state highway right of way. 18. MATERIALS AND WORKMANSHIP All material and workmanship shall conform to the current edition of the Washington State Department of Transportation 6WDQGDUG6SHFL¿FDWLRQVIRU5RDG%ULGJHDQG0XQLFLSDO&RQVWUXFWLRQDQGDPHQGPHQWVWKHUHWRDQGVKDOOEHVXEMHFWWR LQVSHFWLRQDQGFRQFXUUHQFHE\:6'27$Q\:6'27LQVSHFWLRQRUDFFHSWDQFHVKDOOEHIRUWKHVROHEHQH¿WRI:6'27 and not for the Permit Holder or any third party. 7KH:DVKLQJWRQ6WDWH'HSDUWPHQWRI7UDQVSRUWDWLRQ6WDQGDUG6SHFL¿FDWLRQVIRU5RDG%ULGJHDQG0XQLFLSDO&RQVWUXFWLRQ (M41-10) may be accessed at: http://www.wsdot.wa.gov/Publications/Manuals/M41-10.htm 19. PERMIT MODIFICATIONS, AMENDMENTS, CHANGES AND/OR CORRECTIONS :6'27UHVHUYHVWKHULJKWWRUHTXLUHSHUPLWPRGL¿FDWLRQVDPHQGPHQWVFKDQJHVDQGRUFRUUHFWLRQVVKRXOGWKH DXWKRUL]HGFRQVWUXFWLRQQRWFRQIRUPZLWK:6'27¶VFXUUHQW6WDQGDUG6SHFL¿FDWLRQVIRU5RDG%ULGJHDQG0XQLFLSDO Construction, WSDOT’s Standard Plans, WSDOT’s Design Manual, the permit Special Provisions and/or if unexpected construction site conditions are encountered prior to or during the performance of the work authorized by this permit. The Permit Holder is required to obtain WSDOT’s prior review and written approval for any proposed changes to the permit. Permit Holder agrees on behalf of itself, its successors, assigns, tenants, invitees, licensees, contractors, agents and employees, that WSDOT shall in no way be held liable for any delays, costs, or other claims or damages to the Permit Holder or its successors, assigns, tenants, invitees, licensees, contractors, agents and/or employees, should WSDOT UHTXLUHDQ\PRGL¿FDWLRQVDPHQGPHQWVFKDQJHVDQGRUFRUUHFWLRQVWRWKHSHUPLW 20. STORAGE OF EQUIPMENT AND MATERIALS The Permit Holder shall not place or store any equipment and/or materials within the state highway right-of-way unless VSHFL¿FDOO\DXWKRUL]HGE\WKLVSHUPLWRULQZULWLQJE\:6'27DQGDQ\SODFHPHQWRUVWRUDJHRIDQ\HTXLSPHQWDQGRU materials, if allowed, shall only be during the active construction phase of the work authorized by this permit. 21. CONSTRUCTION AND MAINTENANCE WORKING DAYS – SUSPENSION OF WORK 7KH3HUPLW+ROGHUVKDOOQRWSHUIRUPZRUNRQD6DWXUGD\6XQGD\RUDOHJDOKROLGD\XQOHVVVSHFL¿HGHOVHZKHUHLQWKLV permit or by WSDOT in writing. RCW 1.16.050 lists the following days as the observed legal holidays and their common names: • First day in January - New Year’s Day • Third Monday of January - Martin Luther King Jr’ s Birthday • Third Monday of February - President’s Day • Last Monday of May - Memorial Day • Fourth day of July – Fourth of July • First Monday in September - Labor Day DOT Form 224-005 Revised 04/2020 Page 5 • Eleventh day of November - Veterans’ Day • Fourth Thursday in November – Thanksgiving Day and the day immediately following • 7ZHQW\¿IWKGD\RI'HFHPEHU&KULVWPDV'D\ 22. FAILURE TO COMPLETE WORK IN A TIMELY MANNER The Permit Holder agrees to complete the work authorized by this permit within 120 days, unless an extension of time is granted in writing by WSDOT. Should the Permit Holder fail to complete the work within the approved time limit, WSDOT shall determine what work must be completed to restore the state highway right-of-way back to a condition DQGFRQ¿JXUDWLRQWKDWLVVDIHIRUSXEOLFXVH6KRXOGWKH3HUPLW+ROGHUIDLOWRLPPHGLDWHO\¿QLVKWKHZRUNDXWKRUL]HGE\ WKLVSHUPLWRUWRUHVWRUHWKHVWDWHKLJKZD\ULJKWRIZD\EDFNWRDFRQGLWLRQDQGFRQ¿JXUDWLRQWKDWLVVDIHIRUSXEOLFXVH DIWHUUHFHLYLQJZULWWHQQRWLFHRIWKHGH¿FLHQF\IURP:6'27:6'27UHVHUYHVWKHULJKWWRSHUIRUPWKHQHFHVVDU\ZRUN to preserve the state highway for public use and for the safety of the traveling public. If WSDOT performs the work, the Permit Holder agrees to make payment to WSDOT within thirty (30) calendar days of the date of WSDOT’s detailed invoice. If WSDOT chooses not to perform the work, WSDOT may initiate an action to revoke this permit as provided as provided by WAC 468-51.120, as well as recover all costs associated with restoring the state highway right-of-way. 23. FINAL INSPECTION AND SURETY RELEASE $OOZRUNRQVWDWHKLJKZD\ULJKWRIZD\LVVXEMHFWWRRQJRLQJPRQLWRULQJDQGLQVSHFWLRQE\:6'27VROHO\IRUWKHEHQH¿W of WSDOT and not for the Permit Holder or any third party. Upon completion of the work authorized by this permit, LQFOXGLQJWKHUHPRYDORIDOOFRQVWUXFWLRQUHODWHGUXEELVKDQGGHEULVWKH3HUPLW+ROGHUVKDOOUHTXHVWD¿QDOLQVSHFWLRQIURP WSDOT’s representative. Only upon WSDOT’s inspection and concurrence of the work authorized by this permit will WSDOT release the surety, if any, that was made a condition of this permit, provided all other conditions related to the surety have been met. 24. ON-GOING MAINTENANCE OF ACCESS CONNECTION The Permit Holder, its successors or assigns, shall be responsible for maintaining the access connection and related appurtenances between the state highway edge of shoulder and the state highway right-of-way line, including but not limited to, pavement surface, culverts, catch basins, earthen embankment slopes above and below the access FRQQHFWLRQYHJHWDWLRQJURZWKWKDWLPSDFWVWUDႈFDQGSHGHVWULDQVLJKWOLQHVDQGVLJKWGLVWDQFHWKHUHPRYDORIVQRZRU other material that may be tracked onto the access such as mud and debris, and mail boxes. 7KH3HUPLW+ROGHUVKDOOFRUUHFWDQ\PDLQWHQDQFHGH¿FLHQF\ZLWKLQWKLUW\FRQVHFXWLYHFDOHQGDUGD\VXSRQGLVFRYHU\ RU:6'27ZULWWHQQRWLFHXQOHVV:6'27DXWKRUL]HVLQZULWLQJDGLႇHUHQWWLPHSHULRG6KRXOGWKH3HUPLW+ROGHUIDLOWR FRUUHFWDGH¿FLHQF\DIWHUUHFHLYLQJZULWWHQQRWLFHRIWKHGH¿FLHQF\IURP:6'27:6'27UHVHUYHVWKHULJKWWRSHUIRUP the necessary maintenance work to preserve the state highway right-of-way or for the protection of the traveling public or pedestrians. If WSDOT performs maintenance work as provided herein, the Permit Holder agrees to make payment to WSDOT within thirty (30) calendar days of the date of WSDOT’s detailed invoice. If WSDOT chooses not to make the repair, WSDOT may initiate an action to revoke this permit as provided as provided by WAC 468-51.120. 25. STORMWATER AND DRAINAGE MAINTENANCE 7KH3HUPLW+ROGHUVKDOOFRQVWUXFWDQGPDLQWDLQWKHDFFHVVFRQQHFWLRQVXFKWKDWQRVWRUPZDWHUUXQRႇLVGLUHFWHGRQWRWKH paved surface of the state highway traveled lanes and shoulders. Curbing or other drainage features may be required LIWKHJUDGHEH\RQGWKHHGJHRIVKRXOGHULVÀDWRUVORSHVWRZDUGWKHVWDWHKLJKZD\SDYHPHQWVXFKWKDWDQ\VWRUPZDWHU UXQRႇRQWKHDFFHVVFRQQHFWLRQZRXOGÀRZRQWRWKHWUDYHOHGODQHVDQGVKRXOGHURIWKHVWDWHKLJKZD\ The Permit Holder shall be responsible to maintain all culverts and catch basins associated with this permit and shall SURYLGHDOOQHFHVVDU\RQJRLQJPDLQWHQDQFHWRNHHSWKRVHFXOYHUWVDQGFDWFKEDVLQVIUHHÀRZLQJDQGFOHDURIDOO obstructions in accordance with the provisions of Section 24. The Permit Holder shall not interfere with the conveyance and/or treatment of the existing highway stormwater drainage system. If the work performed in any way adversely interferes with existing state highway stormwater drainage, including the treatment and/or conveyance of stormwater, the Permit Holder shall immediately correct its drainage impacts on the state highway at its own expense after receipt of WSDOT’s written notice. Such work as required by WSDOT shall be inspected and concurred to by WSDOT. Any WSDOT notice, requirement, inspection and/or concurrence shall be VROHO\IRUWKHEHQH¿WRIWKHVWDWHDQGQRWIRUWKH3HUPLW+ROGHURUDQ\RWKHUWKLUGSDUW\6KRXOGWKH3HUPLW+ROGHUIDLOWR LPPHGLDWHO\PDLQWDLQRUFRUUHFWDQ\VWRUPZDWHUFRQYH\DQFHGUDLQDJHRUWUHDWPHQWGH¿FLHQF\DIWHUUHFHLYLQJZULWWHQ QRWLFHRIWKHGH¿FLHQF\IURP:6'27:6'27UHVHUYHVWKHULJKWWRSHUIRUPWKHQHFHVVDU\ZRUNWRSUHVHUYHWKHVWDWH highway right-of-way or for the protection of the traveling public or pedestrians. If WSDOT performs the work as provided herein, the Permit Holder agrees to make payment to WSDOT within thirty (30) calendar days of the date of WSDOT’s detailed invoice. If WSDOT chooses not to perform the work, WSDOT may initiate an action to revoke this permit as DOT Form 224-005 Revised 04/2020 Page 6 provided as provided by WAC 468-51.120. 26. RIGHT-OF-WAY VEGETATION MAINTENANCE 7KH3HUPLW+ROGHUVKDOOQRWFXWVSUD\UHWDUGUHPRYHGHVWUR\GDPDJHGLV¿JXUHRULQDQ\ZD\PRGLI\WKHSK\VLFDO condition of any vegetative material located within the state highway right-of-way for any reason, except for the work VSHFL¿FDOO\GHWDLOHGVKRZQDQGDXWKRUL]HGLQWKLVSHUPLW,ILWEHFRPHVQHFHVVDU\WRLQFUHDVHWKHVLJKWOLQHVDQG sight distance at this access connection for safety purposes, the Permit Holder shall contact WSDOT to obtain prior ZULWWHQDSSURYDOIRUDQ\YHJHWDWLYHPDWHULDOPRGL¿FDWLRQORFDWHGRQWKHVWDWHKLJKZD\ULJKWRIZD\LQFOXGLQJREWDLQLQJ :6'27¶VSULRUZULWWHQDXWKRUL]DWLRQIRUYHJHWDWLYHPDWHULDOPRGL¿FDWLRQWRSURYLGH3HUPLW+ROGHUSURSHUW\VLJQRUIDFLOLW\ YLVLELOLW\IURPWKHVWDWHKLJKZD\7KLVLQFOXGHVDQ\PRGL¿FDWLRQVWRWKHHDUWKHQHPEDQNPHQWRQHLWKHUVLGHRIWKHDFFHVV connection. The unauthorized cutting of timber or damage to the vegetative material is prohibited. Criminal penalties may apply under RCW 47.40.080. Civil penalties may apply under RCW 4.24.630. The Permit Holder agrees that it shall perform all restoration work at its sole cost and expense to the satisfaction of WSDOT. 27. FUTURE ACCESS PERMIT MODIFICATIONS BY WSDOT AND RIGHT OF ENTRY In WSDOT’s sole discretion as part of its highway work program, existing permitted access connections may require PRGL¿FDWLRQUHORFDWLRQRUUHSODFHPHQWLQRUGHUWRPHHWFXUUHQW:6'27GHVLJQVWDQGDUGV:6'27VKDOOEHUHVSRQVLEOH WRSHUIRUPVXFKPRGL¿FDWLRQVUHORFDWLRQVRUUHSODFHPHQWVDW:6'27¶VVROHFRVWDQGH[SHQVH7KH3HUPLW+ROGHU hereby authorizes WSDOT to enter upon its lands only where necessary to modify, relocate, or replace all or a portion RIWKHSHUPLWWHGDFFHVVFRQQHFWLRQDQGWRPDLQWDLQWUDႈFFRQWUROGHYLFHVDQGDSSXUWHQDQFHVDVVRFLDWHGZLWK:6'27¶V work performed on or near the permitted access connection. 6KRXOGWKH3HUPLW+ROGHUUHTXHVWWKDWIXUWKHUHQKDQFHPHQWVRUPRGL¿FDWLRQVEHDGGHGWR:6'27¶VZRUN:6'27DW LWVVROHRSWLRQPD\DOORZWKHIXUWKHUHQKDQFHPHQWVRUPRGL¿FDWLRQVEHDGGHGWRLWVZRUNSURJUDPSURYLGHGDOOFRVWVWR SHUIRUPWKHDGGLWLRQDOHQKDQFHPHQWVRUPRGL¿FDWLRQVLVDWWKHVROHH[SHQVHRIWKH3HUPLW+ROGHU7KH3HUPLW+ROGHU agrees to remit the estimated costs of the work to WSDOT before WSDOT will perform the additional enhancement or PRGL¿FDWLRQZRUN:6'27DJUHHVWRUHLPEXUVHWKH3HUPLW+ROGHUIRUPRQLHVSDLGEXWQRWXVHGIRUWKHZRUNZLWKLQWKLUW\ (30) calendar days after the work is performed. The Permit Holder agrees to reimburse WSDOT for all additional costs should they exceed the estimated cost paid within thirty (30) calendar days after receipt of a detailed WSDOT notice. 28. FUTURE ACCESS MODIFICATIONS BY THE PERMIT HOLDER The Permit Holder shall immediately notify WSDOT of any changes made or proposed in the use, intensity of GHYHORSPHQWW\SHRIWUDႈFRUWUDႈFÀRZRIWKHSURSHUW\RUSURSHUWLHVVHUYHGE\WKLVDFFHVVFRQQHFWLRQSHUPLW:6'27 PD\UHTXLUHIXUWKHUWUDႈFDQDO\VHVE\WKH3HUPLW+ROGHULIWKHFKDQJHLVVLJQL¿FDQWWKDWZRXOGUHTXLUHDQHZDFFHVV FRQQHFWLRQSHUPLWDQGRUPRGL¿FDWLRQVWRWKHDFFHVVFRQQHFWLRQ7KHFRVWRIDPRGL¿FDWLRQWRWKLVDFFHVVFRQQHFWLRQ VKDOOEHWKHVROHUHVSRQVLELOLW\RIWKH3HUPLW+ROGHULQFOXGLQJWKHFRVWRIPRGL¿FDWLRQRIDQ\DFFHVVFRQQHFWLRQUHTXLUHG as a result of changes to property site use in accordance with WAC 468-51-110, except as provided in Section 17 of this permit. 29. MODIFICATION OR REVOCATION OF PERMIT OR CLOSURE OF ACCESS CONNECTION In addition to other provisions of this permit, WSDOT may initiate an action to modify, revoke, or close this permit in DFFRUGDQFHZLWKWKHVSHFL¿FWHUPVRI:$&DQGLQFOXGLQJLI • 6LJQL¿FDQWFKDQJHVKDYHRFFXUUHGLQWKHXVHGHVLJQRUWUDႈFÀRZRIWKHSURSHUW\RURIWKHVWDWHKLJKZD\ requiring the relocation, alteration or closure of the access connection, or • 7KHFRQQHFWLRQZDVQRWFRQVWUXFWHGDWWKHORFDWLRQRUWRWKHGHVLJQVSHFL¿HGLQWKHSHUPLWRU • The permit provisions were not met, or • The connection causes a safety, maintenance, and/or operational problem on the state highway system. The Permit Holder may have appeal rights as provided under WAC 468-51-150. In addition, WAC 468-51-120(3) authorizes WSDOT to take immediate remedial action, including the closure of an access connection, if there is an immediate and serious danger to the public health, safety, and welfare, in compliance with chapter 47.32 RCW. This permit is also subject to any and all causes of revocation as allowed by state laws, as amended. DOT Form 224-005 Revised 04/2020 Page 7 30. ASSIGNMENT OF PERMIT 7KLVSHUPLWLVDVVLJQHGWRWKHLGHQWL¿HGSDUFHOVVHUYHGE\WKHDFFHVVFRQQHFWLRQDQGVKDOOUHPDLQDSSXUWHQDQWWRWKH LGHQWL¿HGSDUFHOV6KRXOGWKHLGHQWL¿HGSDUFHOVEHLQKHULWHGVROGDVVLJQHGRUWUDQVIHUUHGLQDQ\ZD\WKLVSHUPLW VKDOOUXQZLWKWKHODQGWRWKHH[WHQWWKDWWKHLGHQWL¿HGSDUFHOVUHPDLQLQFRPSOLDQFHZLWKWKHWHUPVRIWKLVSHUPLWXQOHVV WKHSHUPLWLVUHYRNHGPRGL¿HGRUFORVHGE\:6'27DVSURYLGHGE\ODZRUWKHFXUUHQW3HUPLW+ROGHUUHTXHVWVWKH cancellation of the permit and closure of the access. 31. HIGHWAY ADVERTISING CONTROL No signs shall be placed on state highway right-of-way. Any advertising adjacent to the state highway shall be in compliance with the Scenic Vistas Act of 1971, chapter 47.42 RCW and chapter 468-66 WAC. 32. APPLICABLE WAC’s AND RCW’s ,QDGGLWLRQWRWKHVSHFL¿FVWDWHODZVDQGUXOHVLGHQWL¿HGLQWKLVSHUPLWWKLVSHUPLWLVDOVRVXEMHFWWRDOODSSOLFDEOHSURYLVLRQV of chapters 468-51 and 468-52 WAC, and chapters 47.32, 47.44, and 47.50 RCW, and amendments thereto. 33. AMERICANS WITH DISABILITIES ACT This permit is subject to all applicable provisions of the United States Government American’s with Disabilities Act (ADA). $Q\FXUUHQWRUIXWXUHZRUNVKDOOFRPSO\ZLWKDOODSSOLFDEOH$'$UHTXLUHPHQWVLQHႇHFWDWWKHWLPHRIWKHZRUN DOT Form 224-005 Revised 04/2020 Page 8 DOT Form 224-713 Revised 12/2020 Page 1 Special Provisions for Access Connection Permit Managed Access Highways Only Not for use within an Incorporated City or Town Permit No. Applicable provisions are denoted by ( ) 1. No work provided by this permit shall be performed until the Permit Holder is authorized by the following WSDOT representative: 2. The Permit Holder shall only perform the construction work authorized by this permit during the following work hours: 3. The Permit Holder, unless specified otherwise in this permit, shall only implement the Traffic Control Plans approved for this permit during the following work hours: 4. Pre-Paving Inspection The Permit Holder shall contact WSDOT to request a pre-paving inspection prior to paving any Hot Mix Asphalt (HMA) or Bituminous Surface Treatment (BST). No paving shall occur without first receiving WSDOT’s prior written approval to pave. Failure to obtain this approval may result in WSDOT directing the Permit Holder to remove, repair, and/or add more paving at the Permit Holder’s sole cost and expense. The pre-paving inspection is required to permit WSDOT to verify that the paving, before it is placed, will meet WSDOT’s design requirements for the access connection. Items to be inspected include, but are not limited to, paving limits, culvert placement, material installation, side slopes, and grading of the access connection to Mon-Fri, 8A-4P (daily) Connie Rae/Nate Bergeman 1707 S. C St. Port Angeles, WA 98363 360-565-0680 Shoulder Closure - Mon-Fri, 8A-4P (daily) Lane Closure - Mon-Fri, 8A-2P (daily) 60687 DOT Form 224-713 Revised 12/2020 Page 2 ensure that stormwater will not flow onto the existing state highway pavement after the access connection paving is completed. 5. Paved Access Connection The Access Connection shall be constructed with the following materials, listed from top lift to bottom lift. The thicknesses shown are minimum requirements, as additional material may be necessary to properly construct the access connection. See Exhibit “ “ for design details and paving requirements inches of Mix Asphalt (HMA) Bituminous Surface Treatment (BST), also known as chipseal inches Crushed Surfacing Top Course (CSTC) inches Crushed Surfacing Base Course (CSBC) inches of Rock Cap Geotextile for separation or soil stabilization 6. Gravel Access Connection The Access Connection shall be constructed with the following materials, listed from top lift to bottom lift. The thicknesses shown are minimum requirements. WSDOT may require additional material as necessary to properly construct the access connection. See Exhibit “ “ for additional desgin details and gravel requirements inches Crushed Surfacing Top Course (CSTC) inches Crushed Surfacing Base Course (CSBC) inches of Quarry Spalls inches of Rock Cap Geotextile for separation or soil stabilization 7. Culvert Installation The access connection shall include the installation of a culvert installed in a straight line and with a grade that matches the existing grade of the highway ditch or swale such that the existing conveyance of stormwater will not be adversely impacted. The culvert to be installed shall be inch minimum diameter culvert 8. Culvert Beveled End Treatments The open ends of the culvert run shall be beveled to match the existing slopes of the ditch or swale and access connection fill material. 9. Culvert End Treatments – Quarry Spalls Quarry spalls shall be placed around the open ends of the culvert. The quarry spalls shall be placed below, along the sides, and on the top of the open end of the culvert for a minimum length of two (2) feet in all directions. 10. Gated and Locked Access This access connection shall be gated and locked when not in active use. 11. Surety To ensure proper compliance with all terms and conditions of this permit, a surety amount in the form of a Bond, Assignment of Escrow, Certificate of Deposit, Irrevocable Letter of Credit, Check or Money Order shall be provided to WSDOT in the amount listed below. If a bond is provided, it shall be written by a surety company authorized to do business in the State of Washington. The surety amount shall be: The surety bond shall remain in force until all work under this permit has received final concurrence by WSDOT, and WSDOT issues a written release of the surety bond. D 3 3 DOT Form 224-713 Revised 12/2020 Page 3 12.Temporary Access Connection This is a temporary access connection that shall be immediately closed and removed by the Permit Holder when no longer needed, or by the date listed below, whichever comes first: When the access connection is removed, the Permit Holder shall restore the state highway right-of-way to its original condition, including reseeding if required. Failure by the Permit Holder to remove the access connection as specified herein may result in WSDOT removing the access connection at the Permit Holder’s expense. 13.Access Connection for Emergency Use Only This access connection is for emergency use only and shall be gated and locked at all times to the general public. 14.This is a Non-Conforming Access Connection Permit: Per WAC 468-52-040 Private direct access to the state highway system shall be permitted only when the property has no other reasonable access to the general street system or if access to the general street system would cause traffic operational conditions or safety concerns unacceptable to the local governmental entity. When direct access must be provided the access connection shall continue until such time that other reasonable access to a highway with a less restrictive access control classification or acceptable access to the general street system becomes available and is permitted. It does not meet the minimum spacing from another adjacent driveway or public road intersection of: 125 feet 250 feet 330 feet 660 feet 1320 feet It does not meet the minimum corner clearance standards of WAC 468-52-040(6) of 75 feet 100 feet 115 feet 125 feet 230 feet It exceeds the number of access points for one parcel or contiguous parcels under the same ownership by one or more additional access connections. The existing topography, site conditions, and/or wetland or stream restrictions and buffers prevent the access to be constructed to current standards. Therefore, this access connection shall only continue until such time that a conforming access connection can be constructed or another access to the local street system becomes available and is permitted. Variance Access Connection Permits are only issued on Class 2 through 5 highways. 15. This is a Variance Access Connection Permit: Variance Access Connection Permits (WAC 468-51-105) may be issued, at the discretion of WSDOT, for certain connections not meeting the access classification location and spacing or that exceed the number of connections allowed by the standards adopted for a particular highway segment. It does not meet the minimum spacing from another adjacent driveway or public road intersection of: 125 feet 250 feet 330 feet 660 feet It does not meet the minimum corner clearance standards of WAC 468-52-040(6) of: 75 feet 100 feet 115 feet 125 feet 230 feet It exceeds the number of access points for one parcel or contiguous parcels under the same ownership by one or more additional access connections. The existing topography, site conditions, and/or wetland or stream restrictions and buffers prevent the access to be constructed to current standards. Therefore, this access connection shall only continue until such time that a conforming access connection can be constructed or another access to the local street system becomes available and is permitted. Source: Esri, Maxar, GeoEye, Earthstar Geographics, CNES/Airbus DS, USDA, USGS,AeroGRID, IGN, and the GIS User Community, Jefferson County, WA., Pro-West &³These data are provided on an "AS-IS" basis, without warranty of any type, expressed or implied, including but not limited to any warranty as to their performance, merchantability, or fitness for any particular purpose.This map is not a substitute for accurate field surveys or for locating actual property lines and any adjacent features. Jefferson County, WA Date: 4/8/20211:36,112 Parcel Number 901054007 04/08/2021 Owner Mailing Address: CHRISTIE E LAPLUME 2811 EVELYN CT VIENNA VA 22810-7015 Site Address: Section: 5 School District: Port Townsend (50) Qtr Section: SE1/4 Fire District: EJFR (1) Township: 29N Tax Status: Taxable Range: 1W Tax Code: 0111 Planning Area: Discovery Bay (5) Sewer: Drainage: Bank: View 1: View 2: Zoning 1: RR-5 - Rural Residential Zoning 2:Zoning 3: Sub Division: Assessor's Land Use Code: 9100 - Vacant Land Assessor's Land Use Code: Property Description: S5 T29 R1W TAX 5 TAX 15 TAX RR1 Stationary Work Zones Chapter 2 WSDOT Work Zone Traffic Control Guidelines for Maintenance OperationsՈƒƑňƑƑĸƍѳ -];ƏňƐ m;ƏƍƎѴ TCP 1 Typical One-Lane, Two-Way Traffic Control with Flaggers Chapter 2 Stationary Work Zones -];ƏňѴ WSDOT Work Zone Traffic Control Guidelines for Maintenance OperationsՈƒƑňƑƑĸƍѳ m;ƏƍƎѴ TCP 6 Typical Shoulder Closure – High Speed (45 mph or Higher) Chapter 1340 Driveways WSDOT Design Manual M 22-01.17 Page 1340-5 September 2019 Exhibit 1340-1 Driveway Design Template SU-30 and Smaller Notes: [1] Culvert pipe with beveled end treatment (see Chapter 1600). See Hydraulics Manual, Road Approach and Driveway Culverts for details. [2] When the travel lanes are bituminous, a similar surface may be used on the approaches. [3] For mailbox location and type, see Section 1340.07 and Chapter 1600. [4] Not to exceed ±8% maximum algebraic difference from shoulder slope. [5] Vertical alignment not to exceed a 3¼-inch hump or a 2-inch depression in a 10-foot chord From:Christie LaPlume To:Carla Sebastian Cc:John LaPlume; Wes Fetch Date:Tuesday, June 16, 2020 1:15:07 PM To Whom It May Concern: I give Carla Sebastian and Estes Builders, Authorized Agent authority to apply and administer permit activities on my behalf for parcel #901054007. Thank you. V/R, Christie LaPlume 2811 Evelyn Ct, Vienna, VA 22180 703-966-8884 Up Front Parcel Review Parcel Date Completed: Owner Name: Add. Name: Mailing Address: Site Address(es): Parcel Number: S-T-R: --Total Acreage Legal Description Land Use: Flood District:Fire District:Planning Area: Flood Map (FIRM) Panel No: School District Zoning: [ ] Zoning ________________________________________________________________________________ [ ]Setbacks:Front:_______Left Side:__________Right Side: __________ Rear:_______________ Informed by JCC 18.30 or Title 17 for Master Planned Resorts: Shoreline Setback:____________Critical Area Buffer__________________________________________ Building Setback: ______________________________________________________________________ Adjoining Forest Lands: Commercial/ ____________ Rural/______________Inholding_______________ [ ] Lots/Require Declaration of Restrictive Covenant YES NO, submitted: YES NO __________________ [ ] Legal Access to Property YES NO _____________________________________________________ [ ] Parcel Tags or Scanned Documents YES NO List:_________________________________________ [ ] Sepcial Reports Nearby YES NO List:____________________________________________________ [ ] Shoreline Designation: YES NO _______________________________________________________ [ ] Critical Areas Geologically Hazardous Areas YES NO Shoreline Slope Stability:____________Landslide____________Erosion_____Seismic___________ CMZ: none High Risk Moderate Risk Disconnected CMZ__________________________ Report Submitted________________________________________________________________________ FWHCA: YES NO Stream type: __________________________ Pond or Lake < 20 acres________ Marbled murrelet/Spotted owl_____________ marine nearshore______________ Wetlands:YES NO ___________________________________________________________________ Flood:YES NO List FIRM map:_______________________________________________________ Flood Certificate: ______________________________________________________ Aquifer Recharge Area:YES NO___________________________________________________________ SIPZ: none At Risk High Risk Coastal ________________________________________[ ] Site Visit conducted YES NO _____________________________________________________ [ ]Notice Provisions/Disclosure Forest Lands:YES NO Airport YES NO MRL YES NO Agricultural Lands: YES NO No Shooting Zone:YES NO [ ] Archaeology:YES NO _____________________________________________________________ 4 No No 4 No No Intermediate Slope Yes Coastal Geotechnical Report Moderate None 150' No Yes No 267'180' 4 No No No 100' 214'58' Case #: BLD2021-00042 No 901054007 901054007 Yes Wetlands mapped but not present on site--see notes. Geotechnical Report 4 4 NONE 4 No 10' No No 4 No Inadvertent discovery plan required 4 None No 4 4 Yes RR-5 RR-5 March 26, 2021 4 Yes Yes none No Land Use Requirements [ ] SEPA Required:YES EXEMPT _________________________________________________ [ ] Landscaping Required: Yes No_______________________________________________________ [ ] Parking Spaces Required NO 2 Other_______________________________________________ [ ] Building Height: 35' UBC Standard __________________________________________________ [ ]Stormwater: New Impervious Surface_____________Land Disturbing Activity ________________ Min Req #1 thru #5Stormwater Req's: Min Req #2 Min Req #1 thru #9 Engineering ________________ Drainage District Review Required___________ [ ] Stormwater Pollution Prevention Plan Submitted: Yes No __________________________________ [ ] Impervious Surface coverage percentage: __________________________________________ Resource Lands & Public: 10%Rural Residential: 25%Rural Industrial: Per UDC Sec 6.7 Rural Commercial: 60%Area of Building Coverage: 60% in Rural Industrial Lands only [ ] ADMIN: Setbacks entered in Permit Plan case N/A YES ________________________________ New Parcel Tags entered in Permit Plan N/A YES ____________________________________ Special Reports Scanned N/A YES _________________________________________________ [ ] ADU Proposed YES NO Square Footage: ______________________ [ ] Total Building (s) Size:____________________________________________________________ RVC: 20,000 SF CC: 5,000 SF NC: 7,500 SF GC: 10,000 SF All others: subject to septic & water constraints/None specified [ ] Road Classification:_______________________________________________________________ Road Approach:EXISTING NOT REQ'D RAP__________________________________________ [ ] Require Final Zoning Approval/inspection YES NO __________________________________________ [ ] UGA No Protest Agreement YES NO, submitted: YES NO _____________ [ ] Recorded Date of Subdivision:_______________AFN____________________________Over 5yrs=UDC Plat Conditions:_____________________________________<5yrs=Plat Conditions on plat or Old Ordinance Reviewed By: Additional Notes: No No 4 4 4 Geotechnical report prepared by Leroy Surveyors and Engineers, Inc. and findings conclude that the building site is stable. Project is set back 100 feet from top of intermediate hazard slope. No risk incurred by development. Wetland on site is mapped on site, but mapped area is on a 94% slope grade and vegetation present (madrone, fir, vine maple) does not support presence of wetland. Further, DOE shoreline photos do not show wetland features on or near the property. Coastal SIPZ designation does not impact proposal--single family residence is a low intensity land use and water service is public as opposed to well. Engineered stormwater plan submitted with MLA2020-00072, meets minimum requirements #1 through #9 per 2019 SWMMWW. Project approved. N/A N/A State 6% Bryan Benjamin RAP REQ'D 4 Yes 4 No 4 No 18,428 SF N/A 4 2 4 MLA2020-00072 for engineered stormwater 10,235 SF 4 4 4 4 N/A No No Exempt4 4,433 SF 4 4 Not within subdivision Yes 4