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HomeMy WebLinkAboutBLD2003-00290 • • -00290 03 BUILDING PERMIT APPLICATION BL ReviewType: Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD03-00290 Received Date: 5/8/2003 SITE ADDRESS: 32 CONIFER CT PORT LUDLOW, 98365 OWNER: MICHAEL S YESLEY PHONE: (360)437-1677 IRENE C YESLEY 32 CONIFER CT PORT LUDLOW WA 98365 SUBDIVISION: WOODRIDGE VILLAGE DIV 1 Block: Lot: 1 PARCEL NUMBER: 999700001 Section: 21 Township: 28 N Range: 01 E CONTRACTOR: OLYMPIC RIDGE PHONE: 360-598-3942 15940 LINDSEY LANE POULSBO WA 98370 Contractor's License OLYMPRI986NA Expires 8/1/2004 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION ADD DORMER TO EXISTING ATTACHED GARAGE TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP ALT MAIN: VALUATION 20,000.00 ADD'L: HEAT TYPE: PRO CODE EDITION: 1997 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CMY WATER SYSTEM: PUBLIC PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: 3 Exist: 3 Wetland Erosion Prop: Prop: Seismic Streams Total: 3 Total: 3 Flood Way Floodplain Routing Date: ` F&W Landslide Sy �0� �2 Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: APPROVED AP OV Total: MAY 1 5 2003 Jefferson County Plann.ng 7 & B 'Iding Departm t Jefferson Coun Department of Community I velopment S ON 06 621 Sheridan Street,Port Townsend WA 88368[360)378-4450 ' r nor ° \\...„..,, e$ prmot Ao , ° 0 1.s. N I r :s Project Description: t ,P Bui i g Type: Project Type: 3 Y 8 i -g Type: a"Single Family ❑ New —., IL,Wood ❑ Garage Attached/Detached ❑ AAldition __ ❑ Steel ❑ Modular F Alteration/Remodel �sif FFERSC' ❑ Concrete • CREPT. OF CCt,''°!"' ❑ Commercial ❑ Repair l _::.._... _. ❑ Masonry ❑ Multi-family/#of Units ❑ Demolition ❑ Other: ❑ Industrial ❑ Other: Bathrooms: Bedrooms: Type of Sewage Disposal: Type of Heat: Choose one: Existing: 7. Existing: ❑ Sewer Community System ❑ Electricity 0 Oil Proposed: l 1 Proposed: CN ❑ Individual System • ❑ Woodstove Q'Propane Total: Z3 Total: 3 If not sewer,fill out the following: ❑ Heat Pump ❑ Conventional ❑ Alternative ❑ Other Permit# SEP Water Supply: ❑ Private well ❑ Two Party Well❑ Public:Name of water system: „. Square Footage: For Office Use my Main Floor Consistency Review a 2ND Floor Base fee ''21..25 3rd Floor Plan Check fee—655% 203, '- / Htd Basement State Surcharge fee Unhtd Basement Subtotal 534.574, Garage/Carport Pot Water Review fee 52.,. CO Decks 911/Rd Approach fee d Commercial TOTAL 6, L .56, Industrial ff�� Receipt# 5(0,0 Q, Other W,2 it��on t 4c� •.• Let.e Cash/Check# 2-0 (n2.� Total Valuation: Initials—' /!{ K-$ Or �- Date S/ g/Oj Estimated Cos • D Ol 0 ll If within 20 f th reline, Distance to Bank or Ordinary High Water Mark ft.Bank Height ft. By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of oyirrconsequence of flit-canting of this permit. I further agree to provide access and right of entry to Jefferson County nd it's employees,representatives or agents for the purpose of application review and any required later inspections. Access and right of entry to the appc is property or structure shall e requested and shall occur during regular business hours.' Signature: Date: Va7e.3 H:HOME\PLNCNTR\INFOBLDG\FORMS\BLDpermitApplication 11-8-0] BUILDING PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD03-00290 Received Date 05/8/2003 SITE ADDRESS: 32 CONIFER CT PORT LUDLOW, 98365 Issue Date 05/15/2003 APPLICANT: MICHAEL S YESLEY IRENE C YESLEY PHONE: (360)437-1677 32 CONIFER CT PORT LUDLOW WA 98365 SUBDIVISION: WOODRIDGE VILLAGE DIV 1 Block: Lot: 1 PARCEL NUMBER: 999700001 Section: 21 Township: 28 N Range: 01 E CONTRACTOR: OLYMPIC RIDGE 15940 LINDSEY LANE PHONE: 360-598-3942 POULSBO WA 98370 Contractor's License: OLYMPRI986NA Expires: 08/01/2004 LOAN LENDER/ BOND HOLDER: PROJECT DESCRIPTION: ADD DORMER TO EXISTING ATTACHED GARAGE REQUIRED INSPECTIONS: [ ] SETBACKS /Footings: [ ] Foundation: [ ] Underground Plumbing/Underground Insulation: [ ] Shear Wall: [ ] Framing/Plumbing: ,ON/ 7/#3C - f 1 Propane Tank/Lines: [ ] Insulation: Wilt-L-5 + L41 7-to 0 3 f 1 Sheetrock: f 1 Septic System Final Approval: [ ] Zoning Final Approval: — f`l Final/Occupancy Approval: I--v es I ` fw:L.j` HEALTH DEPARTMENT APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. HOT LINE AVAILABLE 24 HOURS A DAY 26' -0" 18'-0" New Shed Dormer; adjust setout w/ exist.rafters f- -------------------- I I I I I I I I I I At#ic Layout table [verify height req'd] >E - - - Co----------------------- �90" headroom-nnect to exist.SD syste Studio r 19/047/6 D 201 --- --- --- -- -- --- -- -- --- --- -- -------------- \ /I 90 headroom I\ a n I n _I \J Storage Attic I � Attic ;�, ---New walls darker I I Custom Storagq Existing home Toilet/Star. b 11PD.9Tt- �x� vinyl - EX 30"van: .vs/ _ Provide 18"x24' min.attic access ______ _-__- to all attic spaces & cavities Attic o having heights of 3011+ [verify to I iO I I I Option: Re -install exist. skylights on east face of of studio roof. adjust to suit exist.construction. Main Floor Plan - 1 Scale: 1/4" = V-01' 0 N N Extend exist. heating system to studio; suggest using baseboard or wall radiators compatible w/ exist.central heating system R- • Exist. I' I � I �� Exist. I I II �� I " - 1 ply I I L I I V ExistinoiGarage } � I I Verify that exis!t.garage lid qualifies for residential � hr.FR assembly. ✓+Y z{, .5 _ _ _ _ _ _ _ _ Repair any openings into structure above -------- to maintain tire ive construction Q irelrsistiI� L----------------- - ----------------+-- -------I III III 1II II Exist. I X to Exist.OHDR Exist.OHDR Main Floor Plan Scale: 1/4" = V-01I Area Summary Floor Area Floor Area Finshed Floor 0 sf Existing 422 sf 422 sf Code -Heated Floor Area 337 sf 60" min.h t. Exist. Exist. Window Schedule ID Width Height Type Head Ht Glazing Remarks 201 5'0" 3'6" CS 6'0" 17.50 sf 202 5'0" 3'6" CS 6'0" 17.50 sf 203 5'0" 3'6" CS 610" 17.50 sf Sub -total 52.50 sf Window Glazing 8.34 sf Door Glazing 60.84 sf Total Heated Glazing 337 sf Heated Area 18.05 % % of Heated Area Note: Horizontal or vertical sliders may be substituted for casements, verify any egress requirements as noted above. Door Schedule D Width Height Type GlazingRemarks 201 2'6" 6'8" HL-HG 8.34sfExisting-Safety 202 2'6" 6'8" PNL-HG 0.00 sf 8.34 sf Total Door Glazing s n/6 �r ovs &.2l ..s1p Door Notes:. All exterior doors to be 6'8" high [uno] and to align w/ head of windows. All exterior doors shall be weatherstripped and have threshold between 1/2"to 1" Any door glazing shall be safety -rated. Stair Notes: Stairs shall be 36"min.clear w/ 6'8"min. clear headroom abv. each riser nosing -See Sections w/ risers between 4"minimum/8"maximum w/ treads between 9" minimum/ 12"maximum [uno] w/ maximum riser difference not to exceed 3/8" on any run of stairs. All stairs more than 3 risers shall have a 1-112" 0 handrail @ one side min. Handrails shall be installed 34"-38" abv. riser nosing or landings and setout 1-112". Verify handrails secured to framing. Guardrail Notes: Provide guardrails wherever differential floor elevations exceed 30". Install and secure top rail @ 36"min.abv. higher floor. Support guardrail by pony wall or open rail system. Any open railing system shall have all openings less than 4" in one direction [less than 6" @ stair riser] and shall be capable of supporting loads per Load Table. Any glazing incorporated into a guardrail system shall be rated as safety glazing. JEFFERSON COUNTY DCO BUILDING PLAN REVIEW Residential Energy Standards 2001 Climate Zone 1 Heating Source - Gas Hydronic Prescriptive Path - Option IV Total Glazing Area 60.84 sf Heated Floor Area 337 sf Glazing/Heated Floor 18.05 Insulation Min.Standards uno.on Wall Section Flat Ceiling/Roof R-38 Sloping Ceiling/Roof R-30 Above Grade Walls R-21 Below Grade Walls R-21 Floors Above Crawlspace R-30 Perimeter Slab on Grade R-10 Doors U-0.20 Vertical Glazing U-0.40 Overhead Glazing U-0.58 Ducts in Unheated Areas R-8 HW Piping in Unheated Areas R-3 Hot Water Tank Base R-10 Contractor shall submit Final Glazing and Door Schedule as required by local code authority. Mechanical -Hot Water Heaters shall have a min. EF-0.58 -Prescriptive HVAC Heating load not to exceed 36,080 Stuh unless load calculations provided. -Provide minimum one adjustable thermostat in each heating zone providing a control range as follows: Heating only-55'F to 75'F Heating and Cooling - 557 to 857 with adjustable 10' min. deadband Verify if skylight reinstallation option used; this will add 16 more sf to window area; however, as Option IV is unlimited glazing, the above will still comply, residential Ventilation Standards Contractor shall provide a whole house ventilation system providing: 80 cfm min. to 120 cfm max. 0.35 ACH min, to 0.5 ACH max. Using on of the following systems: Whole House Exhaust Central Fan w/ 0.25 inches water -flow rating with noise rating of 1.5 sons. Controlled by 24 hr.automatic timer w/ manual over- ride: set initially for 8 hour per day. Individual habitable outdoor inlets providing 4 sq.in. net free ventilation. Integrated Forced Air Ventilation System Central force air system with outdoor air inlet connected to the return air a min. of 48" from the air handler. Outdoor air is controlled by motorized damper, adjusted flow damper or automatic flow device. Heat Recovery Ventilation System Central independent ventilation system with balanced dampers on inlet and exhaust. Use 6"min.diameter ducts. Contractor shall provide source specific exhaust shall be provide each kitchen, bath, wuter closet, and utility. 50 cfm minimum except 100 cfm in Kitchens Provide manual, timer, or humidisat control. Provide backf low darner on exhaust. Use 4"diameter duct `or 50 cfm exhaust Use 6" diameter ducts for 100 cfm exhaust Refer to WA.State Ventilation and Indoor Air Quality Code for supplemental details and exceptions. Contact the Building Dent ALL GLASS AND GLAZING SHALL at 3794450 prior to m&" dlenges COMPLY WITH CHAPTER 24,1997 UBC or revisions to the approves AS AMENDED BY N I ' � WASHINGTON STATE / p BUILDING CODE COUNCIL / 3s h �\ of \ \ \ 2 ti \ ti N Sche_matii Scale: 1" = 40 ft / 0 15 0 20 ft 1 Lot Woodridge Plat Port Ludlow WA in 9=G60i3WdNi: - a�:Lie soil ��i� is avia& Mfez au.>z , GENERAL NOTES These drawings are abbreviated in content, showing general building set out, structure, and code compliance, and are intended for design -build projects built by an experienced, licensed Contractor, who is knowledgeable with local codes, ordinances and building practices. Based on final product selection, it will be necessary for the Contractor to provide supplemental details and information. Additional information is available from Will Langemack Ltd. upon request. The Contractor shall verify field conditions and dimensions and shall coordinate final product selection prior to construction or fabrication. Unless otherwise noted, material call -outs are generic. Installation of these components shall be coordinated with the various trades and shall be installed according to product manufacturers' installation guides, shop drawings and/or independent testing reports. While every attempt has been made to provide a cohesive plan set, clarifications, modifications, adjustments and/or corrections may be required during the course of construction. As not to jeopardize the buildings code compliance and structural integrity, it shall be responsibility of the Contractor to notify Will Langemack Ltd prior to executing any significant modification to the building. Code Standards: Uniform Building [Vol.1-3], Plumbing, Mechanical and Fire Codes 1997 National Electrical Code 2002 Material Structural Standards: [Unless otherwise noted on drawings] Wood :Sawn Studs - HF-Stud 2x or 3x Joists/Rafters - HF#2 or btr 4x Beams DF#2 or btr Beams/Stringers DF#1 or btr Posts/Timbers 0F#1 or btr Composite: Glulams 24F-V8 DF/DF Boise Cascade ER-5512 Trus joist ER-4979 Structural Panels: Sheathing APA Rated 24/16 Subfloor APA Rated Sturd-i-floor or 2-4-1 Underlayment APA Rated Underlayment Concrete: Concrete Mix f'c=2500 psi min.@ 28 days for design strength Higher strength concrete may be used for workability and protection for weather and marine exposure. Reinforcing Steel fs-40000 psi min [Grade 40] ASTM A-615 Welded Wire Mat fs=40000 psi min ASTM A-185 Water & Aggregate Clean Steel: Shapes, Angles & Plates ASTM A-36 Round Pipe Fy-35 ksi ASTM A-53 Grade B Tubing Fy-46 ksi ASTM A-500 Grade B Bolts ASTM A-307 Wood Connectors & Accessories -Simpson Strong -tie General Construction and Installation [Unless otherwise noted on drawings] 1- All foundation work shall conform to the prescriptive provisions of UBC 1806[UNO]. 2- All wood construction shall conform to UBC Chapter 23 and specifically the prescriptive provisions of UBC 2320-Conventional Light -Frame Construction. 3- Fastening of various building components shall minimally conform to UBC Table 23-II-8-1 Nailing Schedule. 4- Utilize manufactured and tested components wherever possible. Component installation shall conform to manufacturer's installation guides. 5- Specially fabricated components [eg.trusses and specially steel fabrications] may required special engineering and certification. Verify with local code authority for specific submittal requirements prior to fabrication/installation. 6- Any steel welding shall be performed by a AWI certified welder. Shop fabrication and welding should be performed whenever possible. 7- All work shall be installed plumb and level. Use only new, undamaged materials. 8- All exterior surfaces exposed to weather shall be finished with a weather resistant product or finish. Seal and insulate all exterior surfaces if building is to be heated. 9- Electrical, plumbing and HVAC systems are to be design -built by qualified sub -contractors. Only general qualifying criteria are noted on this plan. Deferred Submittals Verify the extent of supplemental documentation required by local code authority; the following are typical examples: ❑ Truss Design and Shop Drawings ❑ HVAC Design and Shop Drawings 0 Electrical layout and Load Calculations ���� Bin 0 Plumbing Riser Diagrams - See Mechanical Plans 0 z Special Inspections 0 2 9 0 No special inspections required or anticipated "'FUSON COUNTY unless unusual conditions encountered during DCD excavation for foundation system. UBC Classification Occupancy Group: R-3 Single Family Dwelling Assessory Use Construction Type: V-N Proposed Area: 422 sf - Dwelling Remodel of unfinished space Heating Type; Extension of exist. gas hydronic w/ radiators Summary of Work Remove portion of roof over existing unfinished attic room above garage and construct shed dormer. Install small toilet room. Extend heating, plumbing, and electrical systems as req'd for finished habitable space. IFIED DOCUMENTS BE SIGNED IN RED Contractor to verify dimensions, field elevations and site conditions prior to construction. Yesley Studio Remodel by Olympic Ridge, Inc. Cont. No.OLYMPR#066J0 Job No. 2003-96 Issue Date 5-1-2003 Revision Date �'(111 Langemack]td •(N 1 design consulting & support senices �1 1115 �Ningg Penn"., ne bainbndge island, wa 98uo 1 of 2 • • [hi E C E II 6- cb !,,,ci--- w JEFFERSON COUNTYI! , ,.$ - DEPARTMENT OF COMMUNITY DEVELOPMENT JEFFERSON 0 621 Sheridan Street• Port Townsend • Washington 98368 DEPT. 0 GOMMUNl1Y 360/379-4450 • 360/379-4451 Fax http://www.co.jefferson.wa.us/commdevelopment/ Stormwater Calculation Sheet MLA# PROJECT/APPLICANT NAME: aQS1/4c(41. .--- E 1 V LL This stormwater calculation sheet should accompany stand-alone stormwater management permit applications, building permit applications,and other land use approval applications that involve stormwater review. STORMWATER CALULATIONS-IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area)) 2vh.a., sq/ft Structures(all roof area) sq/ft Driveway V sq/ft Driveway sq/ft Sidewalks 0 sq/ft Sidewalks sq/ft Patios O sq/ft Patios sq/ft Solid Decks 0 sq/ft Solid Decks sq/ft Other 0 sq/ft Other sq/ft Total New sq/ft Total Existing sq/ft TOTAL NEW+TOTAL EXISTING* sq/ft *This amount will be used to check total lot coverage Please also indicate the amount of land-disturbing activity, in addition to the creation of impervious surface, that will take place: LAND DISTURBING ACTIVITY Drainfield area cleared () sq/ft Well,Structures, Utilities,etc. 4 sq/ft Driveway C sq/ft Other 0 sq/ft Total Land Disturbance Q sq/ft STORMWATER MGMT PERMIT.DOC REV.12/23/2002 S 0 -0-i ECEOVE NAY,,... . ,t.... , .. / JEFFEFiSON COUNTY ., DEPT. OF COMMUNITY DEVELOPMENT / / ' .. , \ .:- *7 41/ b, .. '"•.- , 5,\c)1/ cr,) , , h ° I . ., . ./ - . '} el' 4 ../. I 1 rIg HOU S 71)/ :/:/:/I' 7-r--y, // . ,.. , . ..0, .., Proposed Poe ,,, . ,... ,• .,,, .. \ . ., ... .,/ \ ,,/,.., -.., -,„ . ., .... , • ,..,, \ • •. . \ , , / \ '... \.--"'`* --4 ,.,. <, \ ' ,, 'ye., *,4.. •.'..?" • r• ' .'.' , , 7.' ! :NA- * --.-A,,, •- k ,. . '.,# , ‘,:.t>. '''Ic.— !...V• ''A-.4.7.- 9'- \•,s,,,,,., ''''',; , ' •r,P. \ , ,.., //4.4. —,_„, . t;),•9).`' ,. . ,, \ .- .. . .,.•-, "s\ \ , . „.. . . . , i •-_,Schetratic .5i te Ptori'\.,,, / --//1 '9 . ..-.., ,,('' ' '-- - •.-.., :'•'' ..,„... - \ ' / re #,. t . , i-0 r o. Itil .\\ Langemack -• -, s/A-- Woodrkt9e. Pio:It -4,44:4,‘,.. ,-..-1.4. ,,,..;.00,,s,..Inc•-•."'"' POrr Ludlow. WA --,:, • . .filL. .,;;;Z=4-7.,:',..,,, 1 . , ONc, 0 • ° JEFFERSON COUNTY No cut.p . DEPARTMENT OF COMMUNITY DEVELOPMENT 4, , . 621 Sheridan Street• Port Townsend •Washington 98368 I f ; ' t' t, qN A,O 360/379-4450. 800/831-2678 . 360/379-4451 Fax I l )s ' �'` E - i'.., . t--�-- www.co.jefferson.wa.us/commdevelopmentIP, f-- www.cojefferson.wa.us/commdevelopment ': Master Land Use Permit Application Form « MAY — 8 2 i _. PROPERTY INFORMATION L JEFFERSONOMMCOUNTY Tax Parcel Number: ® ® L7 ® © © � © QEFT.of Ck1MUNi f Y uE`vELOf'NEtJ' Subdivision Name: (l k90,/j.,,, O,Kt.„G Lot Number: CP Property Size: /,9 the. (acres/square feet) Existing Use of Property: !` t!<t�• Site Address and/or Directions to Property: 1.-2O '01,7/26,e4• CV. �;" f / I (e,/0 APPLICANT&OWNER IINFORMATION Applicant(if applicable): ^ )/ d ' ' �f`� Telephone: Address: �f''��!p .- f __ City: 7,}4t�� j% State: Code: -/5,A) Email Address Applicant's Signature: V Property Owner(s)of Record: l,Z V i,.zs Pt ABC,. Telephone: . / 7— c7, Address: c ("") City: d`td t„ /t k, State:/ Zip Code: '3 if- Email Address I acknowledge that the applican above is applying for a building permit on my property. Owner's Signature: I hereb designs -J®t to act as my agent in matters relating to this application for permit(s). t. /V' (PROPERTY OWN SIGNATURE) r( (DATE) DESCRIPTION OF PROPOSED USE OR ACTIVITYA/ (include separate sheets as necessary) `�ccyetyrt 1Q ,ri; %SAL. [THIS SECTION FOR OFFICE USE ONLY] Refer to the specific sections of the UDC referenced below for more information and further requirements.An asterisk(*) indicates that a supplemental application or questionnaire may be required. Type I Permits Refer to: ❑ Septic Permit/Evaluation of Existing System(EES) UDC Section 6.4.1 and Chapter 8.15 JCC ❑ Building/Demolition Permit UDC Section 3.2.1 and Table 3-1 ❑ Allowed"Yes"Use Consistency Analysis UDC Section 3.2.1 and Table 3-1 ❑ Home Business Table 3-1 and UDC Section 4.20 ❑ Stormwater Management* UDC Section 6.7 ❑ Road Access* UDC Section 6.8 ❑ Boundary Line Adjustment* UDC Section 7.2 , ❑ Minor PRRD Amendments UDC Section 3.6.13.15 ❑ Sign Permit* UDC Section 6.15 ❑ Site Plan Approval Advance Determination (SPAAD) UDC Section 8.7 ❑ Shoreline Master Program Exemption/Permit Revisions UDC Section 5 0 Temporary Use(based on use may be Type II or Type III)* UDC Sections 4.38 and 4.39 (OVER) • • 441 Type II Permits Refer to: ❑ Discretionary"D"or Unnamed Use Classification UDC Sections 3.2.1, 3.2.2 and Table 3-1 ❑ Cottage Industry UDC Section 7.3 and Table 3-1 ❑ Short Plat, Preliminary and Final* UDC Section 7.3 ❑ Binding Site Plan* UDC Section 7.5 ❑ Conditional (Administrative)"C(a)" Use UDC Table 3-1 and Section 8.8 ❑ Conditional(Discretionary)"C(d)" Use UDC Table 3-1 and Section 8.8(Discretionary Permit Review Process Determined by Administrator) ❑ Variance, Minor* UDC Section 8.9 ❑ Wireless Telecommunication Ordinance 06-0712-99(UDC Appendix C) ❑ Shoreline Substantial Development(Primary Use) UDC Section 5 ❑ Forest Practices Act/Release of Six-Year Moratorium for Single- UDC Section 4.16.5(c) Family Residence ❑ Appeal UDC Section 8.4.2 SEPA 8.10.12(b) Type Ill Permits ❑ Conditional"C"Use UDC Section 8.8 ❑ Long Plat, Preliminary* UDC Section 7.4 ❑ Planned Rural Residential Development Preliminary Approval UDC Section 3.6.13(must be in conjunction with an (PRRD)and Major Amendments* underlying land division application) ❑ Plat Vacation/Alteration UDC Section 7.1.3(d) ❑ Variance, Major* UDC Section 8.9 ❑ Reasonable Economic Use Variance* UDC Section 3.6.4(h) ❑ Wireless Telecommunication Ordinance 06-0712-99 UDC Appendix C ❑ Shoreline Management Substantial Development,Secondary Use* UDC Section 5 ❑ Shoreline Management Conditional Use* UDC Section 5 ❑ Shoreline Management Variance* UDC Section 5 ❑ Appeal UDC Section 8.4.3 SEPA 8.10.12(c) Type IV Permits ❑ Long Plat, Final UDC Section 7.4 ❑ PRRD, Final UDC Section 3.6.13 Type V Permits ❑ Special Use(Essential Public Facilities) UDC Section 3.3.5 ❑ Jefferson County Comprehensive Plan/UDC/Land Use District Map UDC Section 9 Amendment* ❑ Jefferson County Shoreline Master Program Amendment* UDC Section 5 ❑ Appeal of SEPA UDC Section 8.10.12(d) Other Local.State or Federal Permits ❑ Please identify any other local, state or federal permits required for this proposal, if known: ACKNOWLEDGEMENTS [PLEASE NOTE THAT TWO SIGNATURES ARE REQUIRED] By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property.Any material falsehood or any omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void. I further agree to save, indemnify and hold harmless Jefferson County against all liabilities, judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further 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. This right of entry shall expire when the County (through the Administrator or the Administrator's representatives)concludes the application has complied with all applicable laws and regulations.Access and right of entry to the appli n' pe ty s all be requested and shall occur only during regular business hours. 1. Sr/r d3 W PROPERTY ONE (DATE) The action or actions Applicant ill undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act" or"ESA." Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual, group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code The Applicant acknowledges that he, she or it holds individual and non-transferable responsibility for adhering to and complying with the ESA. The Appl' ha read his disclaimer and signs and dates it below. 2. PROPERTY OWNER (DATE)