Fillable Department of Community Development DESIGN REVIEW APPLICATION 152 (City of Sequim)

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Department of Community Development DESIGN REVIEW APPLICATION 152 (City of Sequim)

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Revised:
1/1/2020
DESIGN REVIEW APPLICATION
For Department Use Only:
Application Number:
Associated Applications:
Date:
APPLICANT INFORMATION
Owner's Name:
Owner’s E-mail Address:
Owner's Mailing Address:
Owner's Telephone: Business Telephone:
Representative's Name:
Representative’s E-mail Address:
Representative's Mailing Address:
Representative's Telephone:
Are there any critical areas; such as wetlands, critical wildlife habitat, steep slopes (greater than 15%), frequently flooded
areas, irrigation ditches, streams and stream corridors? □ No □ Yes
If yes, attach the appropriate environmental analysis.
This project includes? □ Residential Development (2 or more dwelling units) □ Commercial □ Mixed Use
Please provide the existing Address, Legal Description and/or Parcel Number(s)?
Use and attach additional pages if necessary.
Department of Community Development
152 W Cedar Street
Sequim, WA 98382
(360) 683-4908
www.sequimwa.gov
plus Engineering Review Fee of $770 + hourly after 5 hours
Application Fee
of
$1,000.00
+ $0.25/sq. ft.,
michael@nelsonadvisors.com
425.269.3331
Michael Nelson
PO Box 53308 Bellevue, WA 98015
1300 114th Ave SE Ste. 252 Bellevue, WA 98004
michael@nelsonadvisors.com
425.269.3331
✔
✔
810 W. Brackett Rd. Sequim, WA
Parcel Numbers: 033019230050
CDR20-002
11/19/2020
8.
Legal Description: TX# 6689 SW NW SUR V63 P16
Revised:
1/1/2020
□ Copies of an 18” x 24” or larger Site Plan map prepared by a Washington State licensed and registered
land surveyor or equivalent to drawn at a horizontal scale of 50-feet or fewer to the inch, depicting the
following items and required studies:
□ Elevation Drawings. Complete elevation drawings of all buildings showing dimensions and proposed materials
including roofing, siding, windows and trim. Drawings shall include conceptual trim and cornice design and roof pitch.
If landscaping is proposed to soften or mitigate architectural modulation or details, additional elevation drawings
showing proposed landscaping shall be provided.
□ Equipment Screening. A description of how all mechanical and utility equipment will be screened.
□ Color and Material Palette. The proposed schematic color and material palette for exterior siding, trim, cornice,
windows and roofing of all proposed structures.
□ Critical Areas special studies where required by the Critical Areas Ordinance (SMC 18.70 &18.80); for questions
consult with the City of Sequim Planning Department.
□ Preliminary Stormwater Drainage Plans, prepared consistent with the requirements of SMC Title 13.
□ Estimated quantities of fill exported and imported to the site.
□ Preliminary Site Section Drawings. Section drawings which illustrate existing and proposed grades.
□ Preliminary Grading Plan. An accurate topographic map of the property, delineating contours, (existing and proposed)
at no greater than five-foot intervals. The plan shall indicate all proposed cuts, fills, and retaining wall heights and
include areas of disturbance necessary to construct all retaining walls, structures and impervious surfaces.
□ Site Layout. A plan, drawn to scale no smaller than one inch equals 30 feet showing location and size of all structures,
critical areas, required buffer areas, landscape areas, open spaces, common areas or plazas, walkways, preliminary
stormwater retention/detention facilities, and parking lot layout and vehicle circulation.
Two
□
Title Report or other proof of ownership.
□
State Environmental Policy Act (SEPA) Checklist (fee based on value of project - refer to SEPA Checklist).*
□
A
complete
Design
Review
application with all
required
studies,
submittal
materials, and fees).
□
A
Pre-Application meeting
shall
take place
prior to formal
submittal
of
the
Design
Review
application.
City of Sequim Department of Community Development. ***
are turned in as part of this application. Incomplete applications will not be accepted by the
***It is the responsibility of the applicant to ensure that all submittal requirements listed below
Checklist
Submittal Requirements
Design Review Application
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Revised:
1/1/2020
□ Vegetation Plan. A plan which accurately identifies the species, size and location of all significant vegetation within the
property subject to the application.
□ Location of streams, irrigation ditches, drainage ditches, wetlands, ponds, floodways or other water
proposed project.
□ Location, extent and type of wooded areas and all trees greater than eight inches in diameter, or identified as
species of local significance.
□ Tree Retention Plan. A landscape plan showing the species, size and location of all significant (SMC
17.28.030) natural vegetation to be retained on the property.
□ Adjacent property owners’ list for all properties located within a
County assessor’s office.
□ A scaled vicinity map showing the subject property in reference to surrounding properties, streets, subdivisions,
municipal boundaries, property, and including a north arrow.
□ Copies of any existing and/or proposed deed restrictions or covenants.
□ Preliminary utility plans, including provisions for water, sewer, underground power where appropriate,
telecommunications, and solid waste disposal.
□ Preliminary Utilities Plan. A utilities plan showing the location and type of any utilities proposed in critical areas,
critical area buffers and natural vegetation retention areas.
□ Preliminary landscaping plans
□ Any additional materials, as determined by the department during the required pre-application meeting,
to be necessary to fully evaluate the application.
□ A description of how parking requirements will be met, this should be shown on the site plan.
□ Preliminary road plans including plan, sections, and profiles.
□ Preliminary phasing plan, if proposed.
□ The name of the project.
□ Legal Description of the entire parcel.
□ Date, scale and north arrow.
□ Boundary lines, right-of-way for streets, easements and property lines of lots.
□ Fencing. The location and description of any proposed fencing.
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
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Revised:
1/1/2020
□ Location of all open spaces.
□ Location of all utilities and other improvements, with accurate bearings, dimensions of angles and arcs, and all curve
data describing the location of improvements.
□ Street (right-of-way) widths and names.
□ Lot acreage, dimensions and lot numbers.
□ Locations of private and/or public easements, their dimensions and their purpose.
□ Lighting and Signage. A photometric plan identifying location and height of proposed parking lot, pedestrian and/or
building security light structures and poles. Sign type and location shall be identified. A separate City of Sequim sign
application will be required for additional sign information.
□ Accessories. The location of all outdoor furniture, trash receptacles, recycling areas, bicycle racks and other
accessories.
Owner(s) Date
Design Review.
damages which may be occasioned to any other land or persons by actions authorized by the City of Sequim in relation to this
I certify that the above information is true and correct to the best of my knowledge and accept responsibility for all claims and
necessary for decision making purposes. ***
***The City of Sequim Department of Community Development may require additional information
* May not be required to be submitted in conformance with WAC197-11-800 (Categorical Exemptions).
Representative(s)
Date
✔
✔
✔
✔
✔
✔
✔
11.9.2020
11.9.2020
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 1 of 23
ENVIRONMENTAL REVIEW PACKET AND CHECKLIST
PROJECTS SUBJECT TO DESIGN REVIEW
City of Sequim:
Value of Project Fee
$0 - $250,000 = $600
$250,001 - $500,000 = $825
$500,001-$1,000,000 = $1,540
$1,000,000+ = $2,645
Purpose of Checklist:
The State Environmental Policy Act (SEPA), chapter 43.21C RCW, requires all governmental agencies to
consider the environmental impacts of a proposal before making decisions. An environmental impact
statement (EIS) must be prepared for all proposals with probable significant adverse impacts on the
quality of the environment. The purpose of this checklist is to provide information to help you and the
agency identify impacts from your proposal (and to reduce or avoid impacts from the proposal, if it can be
done) and to help the agency decide whether an EIS is required.
Instructions for Applicants:
This environmental checklist asks you to describe some basic information about your proposal.
Governmental agencies use this checklist to determine whether the environmental impacts of your
proposal are significant, requiring preparation of an EIS. Answer the questions briefly, with the most
precise information known, or give the best description you can.
You must answer each question accurately and carefully, to the best of your knowledge. In most cases,
you should be able to answer the questions from your own observations or project plans without the need
to hire experts. If you really do not know the answer, or if a question does not apply to your proposal,
write "do not know" or "does not apply. " Complete answers to the questions now may avoid delays later.
Some questions ask about governmental regulations, such as zoning, shoreline, and landmark
designations. Answer these questions if you can. If you have problems, the agencies can assist you.
The checklist questions apply to all parts of your proposal, even if you plan to do them over a period of
time or on different parcels of land. Attach any additional information that will help describe your
proposal or its environmental effects. The agency to which you submit this checklist may ask you to
explain your answers or provide additional information reasonably related to determining if there may be
significant adverse impact.
Use of Checklist for Non project Proposals:
Complete this checklist for nonproject proposals, even though questions may be answered "does not
apply." In addition, complete the supplemental sheet for nonproject actions (Part D). For nonproject
actions, the references in the checklist to the words "project," "applicant," and "property or site" should be
read as "proposal, " "proposer, " and "affected geographic area, " respectively.
9.
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 2 of 23
SEPA Review Process
1. A minimum of two (2) sets of stamped, legal size envelopes will need to accompany the
application submittal. The applicant will need to obtain mailing labels for all adjacent property
owners within a 300 foot radius of the subject property. See Instructions for Obtaining Address
Labels on page 3 of this application.
2. Upon acceptance of an application by the City, you will receive a “Determination of
Completeness” (DOC) within 28 days of the submittal of your application stating whether your
application is complete or not complete.
3. A “Notice of Application” (NOA) will be published and sent to adjacent property owners
for comment. The NOA will be issued within 14 days after a DOC is made. You will be
required to post a “Notice Board” (see the attached example) on the property in
conformance with Section 20.01.140 of the Sequim Municipal Code. An “Affidavit of
Installation” shall be submitted to the City that the “Notice Board” has been installed on
the property. The “Notice Board” shall be installed on the property on or before the date
the NOA is published in the paper.
4. The SEPA determination will be issued after the comment period for the NOA has expired.
Notification of the SEPA determination will be in the same manner as a NOA.
5. If a public hearing is required before the Planning Commission, Board of Adjustment, or the City
Council for the permit or action requested, notification will be done in the same manner as with a
NOA and SEPA determination.
6. A “Mitigated Determination of Nonsignificance” (MDNS) or a “Determination of
Nonsignificance” (DNS) will be published and sent to property owners within 300 feet of the
subject property and to all “Parties of Record”. The MDNS or DNS will be sent within 90 days
from the issuance of the DOC. The applicant can request advanced notification if a
“Determination of Significance” (DS) is being considered by the City.
7. The “Notice Board” shall be removed within 30 calendar days of the publication of the Notice of
Decision (NOD).
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 3 of 23
INSTRUCTIONS FOR OBTAINING ADDRESS LABELS
*Please Note – Mailing labels with adjacent property owner addresses may only be
purchased from Clallam County or prepared by a licensed title company. Mailing
labels shall be on a 30 label per page format. Tax Assessor’s map(s) showing the 300
foot radius around the exterior property lines of the proposal shall be submitted with
the application.
REMINDER:
Envelopes and postage shall be provided by the applicant. A copy of the labels shall be
made before individually placing them on stamped legal sized envelopes (9 ½” x 4 ½”)
with the City’s return address. A City of Sequim rubber stamp will be provided to the
applicant upon request for the return address. (NO METERED MAIL)
RETURN ADDRESS:
City of Sequim
Dept. of Community Development
152 W. Cedar St.
Sequim, WA 98382
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 4 of 23
NOTICE BOARD
The notice board shall be four feet (4') by four feet (4') and shall have a sky blue background
with white lettering for the City logo, “Public Notification”, and contact information. Project
lettering, stating the land use/project action shall be blue or black on a white background.
Lettering size shall be the following (the illustration below is an example. The type of action,
dates, and all pertinent information will be supplied by the City):
a. Helvetica or similar standard type face;
4 FT
4 FT
Blue
Background
with White
Lettering
Blue
Background
with White
Lettering
White
Background
with Blue or
Black
Lettering
Real Estate
Box With
Public Notice
Information
Project Type &
Description
(Provided by
Staff)
Staff Name, Phone No., &
Email. This Will be
Provided to the Applicant
The file number and
comment deadline date will
be provided to the applicant
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 5 of 23
SUBMITTAL REQUIREMENTS
Plan Submittal Requirements
Applicant
(Check if
Provided)
Staff
1
A complete application with all required studies and submittal
materials with electronic copies submitted on a flash drive.
2
State Environmental Policy Act (SEPA) Checklist
3
Title Report (no more than 120 days old) or other proof of
ownership as approved by the City.
4
Adjacent property owners’ list for all properties located within
a 300′ foot radius obtained for Clallam County assessor’s
office or other source.
5
A minimum of two (2) sets of stamped, legal size envelopes
addressed to each property owner within 300 feet of the subject
property with the return address for the City of Sequim DCD.
A return address stamp is available for your use upon request.
(NO METERED MAIL)
6
One paper reduction of each oversized plan to 8 ½” x 11” or
11” x 17.
7
3 Copies of an 18” x 24” or larger Site Plan map prepared
by a Washington State licensed and registered land
surveyor or equivalent to drawn at a horizontal scale of 50-
feet or fewer to the inch, depicting the following items and
required studies:
8
Colored Elevation Drawings. Complete colored elevation
drawings of all buildings showing dimensions and proposed
materials including roofing, siding, windows and trim.
Drawings shall include conceptual trim and cornice design and
roof pitch. If landscaping is proposed to soften or mitigate
architectural modulation or details, additional elevation
drawings showing proposed landscaping shall be provided.
Note which elevation is the north, south, west, and east
elevation for all structures on-site; do not label as front, rear, or
sides elevation.
9
Equipment Screening. A description of how all mechanical
and utility equipment will be screened.
10
Color and Material Palette. The proposed schematic color
and material palette for exterior siding, trim, cornice, windows
and roofing of all proposed structures.
11
A scaled vicinity map showing the relationship of the proposed
development to existing streets and surrounding land uses, and
indicating the location of any nearby bodies of water,
wetlands, or other significant natural features. The vicinity
map should indicate all structures located within 300 feet of
the subject property
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 6 of 23
12
Materials Board. Provide a Materials Board with samples of
the proposed exterior surfaces.
13
A Site Plan drawn to scale (1 in. = 20, or 30, or 40 ft.)
showing, at a minimum, the following:
a) Dimension and shape of lot with adjacent street names
b) Location and dimensions of existing and proposed
buildings (engineering scale only) including the
building height of proposed buildings
c) Adjacent street improvements, ingress and egress,
parking layout showing the number of stalls and stall
sizes
d) Off-street parking calculations and requirements
e) Gross floor area.
f) Proposed phasing.
g) Date, scale and north arrow.
h) Boundary lines, right-of-way for streets, easements and
property lines of lots.
i) Fencing. The location and description of any proposed
fencing.
j) Location of all open spaces (existing or proposed).
14
Critical Areas special studies where required by the Critical
Areas Ordinance (SMC 18.80); for questions consult with the
City of Sequim Planning Department.
15
Preliminary Stormwater Drainage Plans, prepared
consistent with the requirements of SMC Title 13.
16
Estimated quantities of fill exported and imported to the site.
17
Preliminary Site Section Drawings. Section drawings which
illustrate existing and proposed grades.
18
Preliminary Grading Plan. An accurate topographic map of
the property, delineating contours, (existing and proposed) at
two-foot intervals. The plan shall indicate all proposed cuts,
fills, and retaining wall heights and include areas of
disturbance necessary to construct all retaining walls,
structures and impervious surfaces.
19
A circulation plan indicating the proposed movement of
vehicles, goods, and pedestrians within the development and to
and from adjacent public arterial, collectors or roadways. Any
special engineering features and traffic regulation devices
needed to insure the safety of this circulation plan shall be
shown.
20
Location of streams, irrigation ditches, drainage ditches,
wetlands, ponds, floodways or other water courses on or within
200′ feet of the proposed project.
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 7 of 23
21
Location, extent and type of wooded areas and all trees greater
than eight inches in diameter, or identified as species of local
significance. Show the location of Garry Oaks regardless of
diameter.
22
Tree Retention Plan. A landscape plan showing the species,
size and location of all significant natural vegetation to be
retained on the property.
23
Lighting and Signage. A photometric plan identifying
location and height of proposed parking lot, pedestrian and/or
building security light structures and poles. Sign type and
location shall be identified. A separate City of Sequim sign
application will be required for additional sign information.
24
Copies of any existing and/or proposed deed restrictions or
covenants.
25
Preliminary Utility Plans, including provisions for water,
sewer, underground power where appropriate,
telecommunications, and solid waste disposal, including
utilities proposed in critical areas, critical area buffers and
natural vegetation retention areas.
26
Location of all utilities and other improvements, with accurate
bearings, dimensions of angles and arcs, and all curve data
describing the location of improvements.
27
Preliminary landscaping plans. A plan showing the species,
size and location of all existing indigenous and native trees
eight inches in diameter or larger, and other significant shrubs,
groundcovers, and ornamental grasses within the property
subject to the application. This plan must also include all
proposed new landscaping.
28
The name of the project.
29
Legal Description of the entire parcel.
30
Accessories, Where Applicable. The location of all outdoor
furniture, trash receptacles, recycling areas, bicycle racks and
other accessories.
***The City of Sequim Department of Community Development may require additional information
necessary for decision making purposes. ***
SEPA Environmental checklist (WAC 197-11-960) July 2016 Page 8 of 23
SEPA ENVIRONMENTAL CHECKLIST
Purpose of checklist:
Governmental agencies use this checklist to help determine whether the environmental impacts of
your proposal are significant. This information is also helpful to determine if available avoidance,
minimization or compensatory mitigation measures will address the probable significant impacts
or if an environmental impact statement will be prepared to further analyze the proposal.
Instructions for applicants:
This environmental checklist asks you to describe some basic information about your proposal.
Please answer each question accurately and carefully, to the best of your knowledge. You may
need to consult with an agency specialist or private consultant for some questions. You may use
“not applicable” or "does not apply" only when you can explain why it does not apply and not when
the answer is unknown. You may also attach or incorporate by reference additional studies
reports. Complete and accurate answers to these questions often avoid delays with the SEPA
process as well as later in the decision-making process.
The checklist questions apply to all parts of your proposal, even if you plan to do them over a
period of time or on different parcels of land. Attach any additional information that will help
describe your proposal or its environmental effects. The agency to which you submit this checklist
may ask you to explain your answers or provide additional information reasonably related to
determining if there may be significant adverse impact.
Instructions for Lead Agencies:
Please adjust the format of this template as needed. Additional information may be necessary to
evaluate the existing environment, all interrelated aspects of the proposal and an analysis of
adverse impacts. The checklist is considered the first but not necessarily the only source of
information needed to make an adequate threshold determination. Once a threshold
determination is made, the lead agency is responsible for the completeness and accuracy of the
checklist and other supporting documents.
Use of checklist for nonproject proposals: [help]
For nonproject proposals (such as ordinances, regulations, plans and programs), complete the
applicable parts of sections A and B plus the SUPPLEMENTAL SHEET FOR NONPROJECT ACTIONS
(part D). Please completely answer all questions that apply and note that the words "project,"
"applicant," and "property or site" should be read as "proposal," "proponent," and "affected
geographic area," respectively. The lead agency may exclude (for non-projects) questions in Part
B - Environmental Elements –that do not contribute meaningfully to the analysis of the proposal.
Page 9 of 23
A. Background [help]
1. Name of proposed project, if applicable: [help]
2. Name of applicant: [help]
3. Address and phone number of applicant and contact person: [help]
4. Date checklist prepared: [help]
5. Agency requesting checklist: [help]
6. Proposed timing or schedule (including phasing, if applicable): [help]
7. Do you have any plans for future additions, expansion, or further activity related to or
connected with this proposal? If yes, explain. [help]
8. List any environmental information you know about that has been prepared, or will be
prepared, directly related to this proposal. [help]
9. Do you know whether applications are pending for governmental approvals of other
proposals directly affecting the property covered by your proposal? If yes, explain. [help]
10. List any government approvals or permits that will be needed for your proposal, if
known. [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
LED lighting through out. EV charging infrastructure.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 10 of 23
11. Give brief, complete description of your proposal, including the proposed uses and
the size of the project and site. There are several questions later in this checklist that
ask you to describe certain aspects of your proposal. You do not need to repeat those
answers on this page. (Lead agencies may modify this form to include additional
specific information on project description.) [help]
12. Location of the proposal. Give sufficient information for a person to understand the
precise location of your proposed project, including a street address, if any, and section,
township, and range, if known. If a proposal would occur over a range of area, provide
the range or boundaries of the site(s). Provide a legal description, site plan, vicinity map,
and topographic map, if reasonably available. While you should submit any plans
required by the agency, you are not required to duplicate maps or detailed plans
submitted with any permit applications related to this checklist. [help]
B. ENVIRONMENTAL ELEMENTS [help]
1. Earth [help]
a. General description of the site: [help]
(check one): Flat, rolling, hilly, steep slopes, mountainous, other
b. What is the steepest slope on the site (approximate percent slope)? [help]
c. What general types of soils are found on the site (for example, clay, sand, gravel,
peat, muck)? If you know the classification of agricultural soils, specify them and note
any agricultural land of long-term commercial significance and whether the proposal
results in removing any of these soils. [help]
d. Are there surface indications or history of unstable soils in the immediate vicinity? If
so, describe. [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 11 of 23
e. Describe the purpose, type, total area, and approximate quantities and total affected
area of any filling, excavation, and grading proposed. Indicate source of fill. [help]
f. Could erosion occur as a result of clearing, construction, or use? If so, generally
describe. [help]
g. About what percent of the site will be covered with impervious surfaces after project
construction (for example, asphalt or buildings)? [help]
h. Proposed measures to reduce or control erosion, or other impacts to the earth, if any:
[help]
2. Air [help]
a. What types of emissions to the air would result from the proposal during construction,
operation, and maintenance when the project is completed? If any, generally describe
and give approximate quantities if known. [help]
b. Are there any off-site sources of emissions or odor that may affect your proposal? If
so, generally describe. [help]
c. Proposed measures to reduce or control emissions or other impacts to air, if any:
[help]
3. Water [help]
a. Surface Water:
1) Is there any surface water body on or in the immediate vicinity of the site
(including year-round and seasonal streams, saltwater, lakes, ponds, wetlands)?
If yes, describe type and provide names. If appropriate, state what stream or river
it flows into. [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 12 of 23
2) Will the project require any work over, in, or adjacent to (within 200 feet) the
described waters? If yes, please describe and attach available plans. [help]
3) Estimate the amount of fill and dredge material that would be placed in or
removed from surface water or wetlands and indicate the area of the site that
would be affected. Indicate the source of fill material. [help]
4) Will the proposal require surface water withdrawals or diversions? Give general
description, purpose, and approximate quantities if known. [help]
5) Does the proposal lie within a 100-year floodplain? If so, note location on the site
plan. [help]
6) Does the proposal involve any discharges of waste materials to surface waters? If
so, describe the type of waste and anticipated volume of discharge. [help]
b. Ground Water:
1) Will groundwater be withdrawn from a well for drinking water or other purposes? If
so, give a general description of the well, proposed uses and approximate
quantities withdrawn from the well. Will water be discharged to groundwater? Give
general description, purpose, and approximate quantities if known. [help]
2) Describe waste material that will be discharged into the ground from septic tanks
or other sources, if any (for example: Domestic sewage; industrial, containing the
following chemicals. . . ; agricultural; etc.). Describe the general size of the
system, the number of such systems, the number of houses to be served (if
applicable), or the number of animals or humans the system(s) are expected to
serve. [help]
c. Water runoff (including stormwater):
Not applicable
Not applicable, no surface waters in the immediate vicinity.
Not applicable, no surface waters in the immediate vicinity.
No
No, all water if any will be contained on site.
No water will be withdrawn from a well as there are none on the property. Domestic and irrigation water will be
drawn from City of Sequim lines. Parking lot and roof water will be treated onsite and discharged into infiltration
trench.
No septic tanks will be used. Building will be tied into City of Sequim Sewer. Parking lot and
roof water will be treated and discharged into infiltration trench.
Parking lot and roof water will be treated on site and discharged into infiltration trench.
Page 13 of 23
1) Describe the source of runoff (including storm water) and method of collection
and disposal, if any (include quantities, if known). Where will this water flow?
Will this water flow into other waters? If so, describe. [help]
2) Could waste materials enter ground or surface waters? If so, generally describe.
[help]
3) Does the proposal alter or otherwise affect drainage patterns in the vicinity of the
site? If so, describe. [help]
d. Proposed measures to reduce or control surface, ground, and runoff water, and
drainage pattern impacts, if any: [help]
4. Plants [help]
a. Check the types of vegetation found on the site: [help]
deciduous tree: alder, maple, aspen, other
evergreen tree: fir, cedar, pine, other
shrubs
grass
pasture
crop or grain
Orchards, vineyards or other permanent crops.
wet soil plants: cattail, buttercup, bullrush, skunk cabbage, other
water plants: water lily, eelgrass, milfoil, other
other types of vegetation
b. What kind and amount of vegetation will be removed or altered? [help]
c. List threatened and endangered species known to be on or near the site. [help]
Parking lot and roof water will be treated on site and discharged into infiltration trench. Parking lot water
will flow into catch basins and from there to treatment device before discharge into infiltration trench.
No
No drainage patterns outside of the site will affected.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 14 of 23
d. Proposed landscaping, use of native plants, or other measures to preserve or
enhance vegetation on the site, if any: [help]
e. List all noxious weeds and invasive species known to be on or near the site. [help]
5. Animals [help]
a. List any birds and other animals which have been observed on or near the site or are
known to be on or near the site. [help]
Examples include:
birds: hawk, heron, eagle, songbirds, other:
mammals: deer, bear, elk, beaver, other:
fish: bass, salmon, trout, herring, shellfish, other
b. List any threatened and endangered species known to be on or near the site. [help]
c. Is the site part of a migration route? If so, explain. [help]
d. Proposed measures to preserve or enhance wildlife, if any: [help]
e. List any invasive animal species known to be on or near the site. [help]
6. Energy and Natural Resources [help]
a. What kinds of energy (electric, natural gas, oil, wood stove, solar) will be used to
meet the completed project's energy needs? Describe whether it will be used for
heating, manufacturing, etc. [help]
b. Would your project affect the potential use of solar energy by adjacent properties?
If so, generally describe. [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 15 of 23
c. What kinds of energy conservation features are included in the plans of this
proposal? List other proposed measures to reduce or control energy impacts, if any:
[help]
7. Environmental Health [help]
a. Are there any environmental health hazards, including exposure to toxic chemicals,
risk of fire and explosion, spill, or hazardous waste, that could occur as a result of this
proposal? If so, describe. [help]
1) Describe any known or possible contamination at the site from present or past
uses. [help]
2) Describe existing hazardous chemicals/conditions that might affect project
development and design. This includes underground hazardous liquid and gas
transmission pipelines located within the project area and in the vicinity. [help]
3) Describe any toxic or hazardous chemicals that might be stored, used, or
produced during the project's development or construction, or at any time
during the operating life of the project. [help]
4) Describe special emergency services that might be required. [help]
5) Proposed measures to reduce or control environmental health hazards, if any:
[help]
b. Noise [help]
1) What types of noise exist in the area which may affect your project (for example:
traffic, equipment, operation, other)? [help]
LED lighting through out. EV charging infrastructure.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
We will not increase discharge of water, electricity used by the building will increase load on
local utility system but will be highly efficient.
Page 16 of 23
2) What types and levels of noise would be created by or associated with the project
on a short-term or a long-term basis (for example: traffic, construction, operation,
other)? Indicate what hours noise would come from the site. [help]
3) Proposed measures to reduce or control noise impacts, if any: [help]
8. Land and Shoreline Use [help]
a. What is the current use of the site and adjacent properties? Will the proposal affect
current land uses on nearby or adjacent properties? If so, describe. [help]
b. Has the project site been used as working farmlands or working forest lands? If so,
describe. How much agricultural or forest land of long-term commercial significance
will be converted to other uses as a result of the proposal, if any? If resource lands
have not been designated, how many acres in farmland or forest land tax status will
be converted to nonfarm or nonforest use? [help]
1) Will the proposal affect or be affected by surrounding working farm or forest land
normal business operations, such as oversize equipment access, the application of
pesticides, tilling, and harvesting? If so, how: [help]
c. Describe any structures on the site. [help]
d. Will any structures be demolished? If so, what? [help]
e. What is the current zoning classification of the site? [help]
f. What is the current comprehensive plan designation of the site? [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 17 of 23
g. If applicable, what is the current shoreline master program designation of the site?
[help]
h. Has any part of the site been classified as a critical area by the city or county? If so,
specify. [help]
i. Approximately how many people would reside or work in the completed project? [help]
j. Approximately how many people would the completed project displace? [help]
k. Proposed measures to avoid or reduce displacement impacts, if any: [help]
L. Proposed measures to ensure the proposal is compatible with existing and projected
land uses and plans, if any: [help]
m. Proposed measures to reduce or control impacts to agricultural and forest lands of
long-term commercial significance, if any: [help]
9. Housing [help]
a. Approximately how many units would be provided, if any? Indicate whether high,
middle, or low-income housing. [help]
b. Approximately how many units, if any, would be eliminated? Indicate whether high,
middle, or low-income housing. [help]
c. Proposed measures to reduce or control housing impacts, if any: [help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 18 of 23
10. Aesthetics [help]
a. What is the tallest height of any proposed structure(s), not including antennas; what
is the principal exterior building material(s) proposed? [help]
b. What views in the immediate vicinity would be altered or obstructed? [help]
c. Proposed measures to reduce or control aesthetic impacts, if any: [help]
11. Light and Glare [help]
a. What type of light or glare will the proposal produce? What time of day would it
mainly occur? [help]
b. Could light or glare from the finished project be a safety hazard or interfere with
views? [help]
c. What existing off-site sources of light or glare may affect your proposal? [help]
d. Proposed measures to reduce or control light and glare impacts, if any: [help]
12. Recreation [help]
a. What designated and informal recreational opportunities are in the immediate
vicinity? [help]
b. Would the proposed project displace any existing recreational uses? If so, describe.
[help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 19 of 23
c. Proposed measures to reduce or control impacts on recreation, including recreation
opportunities to be provided by the project or applicant, if any: [help]
13. Historic and cultural preservation [help]
a. Are there any buildings, structures, or sites, located on or near the site that are over
45 years old listed in or eligible for listing in national, state, or local preservation
registers ? If so, specifically describe. [help]
b. Are there any landmarks, features, or other evidence of Indian or historic use or
occupation? This may include human burials or old cemeteries. Are there any
material evidence, artifacts, or areas of cultural importance on or near the site?
Please list any professional studies conducted at the site to identify such resources.
[help]
c. Describe the methods used to assess the potential impacts to cultural and historic
resources on or near the project site. Examples include consultation with tribes and
the department of archeology and historic preservation, archaeological surveys,
historic maps, GIS data, etc. [help]
d. Proposed measures to avoid, minimize, or compensate for loss, changes to, and
disturbance to resources. Please include plans for the above and any permits that
may be required. [help]
14. Transportation [help]
a. Identify public streets and highways serving the site or affected geographic area and
describe proposed access to the existing street system. Show on site plans, if any.
[help]
b. Is the site or affected geographic area currently served by public transit? If so,
generally describe. If not, what is the approximate distance to the nearest transit
stop? [help]
We will not increase discharge of water, electricity used by the building will increase load on
local utility system but will be highly efficient.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 20 of 23
c. How many additional parking spaces would the completed project or non-project
proposal have? How many would the project or proposal eliminate? [help]
d. Will the proposal require any new or improvements to existing roads, streets,
pedestrian, bicycle or state transportation facilities, not including driveways? If so,
generally describe (indicate whether public or private). [help]
e. Will the project or proposal use (or occur in the immediate vicinity of) water, rail, or air
transportation? If so, generally describe. [help]
f. How many vehicular trips per day would be generated by the completed project or
proposal? If known, indicate when peak volumes would occur and what percentage of
the volume would be trucks (such as commercial and nonpassenger vehicles). What
data or transportation models were used to make these estimates? [help]
g. Will the proposal interfere with, affect or be affected by the movement of agricultural
and forest products on roads or streets in the area? If so, generally describe. [help]
h. Proposed measures to reduce or control transportation impacts, if any: [help]
15. Public Services [help]
a. Would the project result in an increased need for public services (for example: fire
protection, police protection, public transit, health care, schools, other)? If so,
generally describe. [help]
b. Proposed measures to reduce or control direct impacts on public services, if any.
[help]
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
We will not increase discharge of water, electricity used by the building will increase load on
local utility system but will be highly efficient.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 21 of 23
16. Utilities [help]
a. Check the utilities currently available at the site: [help]
electricity, natural gas, water, refuse service, telephone, sanitary
sewer, septic system, other
b. Describe the utilities that are proposed for the project, the utility providing the service,
and the general construction activities on the site or in the immediate vicinity which
might be needed. [help]
C. Signature [help]
The above answers are true and complete to the best of my knowledge. I understand
that the lead agency is relying on them to make its decision.
Signature: ___________________________________________________
Name of signee
Position and Agency/Organization
Date Submitted:
D. supplemental sheet for nonproject actions [help]
(IT IS NOT NECESSARY to use this sheet for project actions)
Because these questions are very general, it may be helpful to read them in conjunction
with the list of the elements of the environment. When answering these questions, be
aware of the extent the proposal, or the types of activities likely to result from the
proposal, would affect the item at a greater intensity or at a faster rate than if the
proposal were not implemented. Respond briefly and in general terms.
1. How would the proposal be likely to increase discharge to water; emissions to air;
production, storage, or release of toxic or hazardous substances; or production of
noise?
Proposed measures to avoid or reduce such increases are:
2. How would the proposal be likely to affect plants, animals, fish, or marine life?
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
We will not increase discharge of water, electricity used by the building will increase load on
local utility system but will be highly efficient.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Michael Nelson
Owner
11/6/2020
Page 22 of 23
Proposed measures to protect or conserve plants, animals, fish, or marine life are:
3. How would the proposal be likely to deplete energy or natural resources?
Proposed measures to protect or conserve energy and natural resources are:
4. How would the proposal be likely to use or affect environmentally sensitive areas or
areas designated (or eligible or under study) for governmental protection; such as
parks, wilderness, wild and scenic rivers, threatened or endangered species habitat,
historic or cultural sites, wetlands, floodplains, or prime farmlands?
Proposed measures to protect such resources or to avoid or reduce impacts are:
5. How would the proposal be likely to affect land and shoreline use, including whether it
would allow or encourage land or shoreline uses incompatible with existing plans?
Proposed measures to avoid or reduce shoreline and land use impacts are:
6. How would the proposal be likely to increase demands on transportation or public
services and utilities?
Proposed measures to reduce or respond to such demand(s) are:
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 23 of 23
7. Identify, if possible, whether the proposal may conflict with local, state, or federal laws
or requirements for the protection of the environment.
DATE CHECKLIST RECEIVED: RECEIVED BY:
Invasive Himalayan blackberry and scotch broom will be removed if still prevalent at time of
project, grass sod layer will be removed as needed for construction.
Page 1 of 2
BUILDING APPLICATION INTAKE FORM
NEW CONSTRUCTION
Staff Intake Initials _______Date______
BP#_________
Minimum drawing size 11” X 17”.
Minimum scale 1” per 10’ for site plan, ¼” per 1’ for structural plans.
Submit application and supporting documents to BuildingDept@SequimWA.gov,
Or by mail to address above, or place in utility payment box at south entrance of building.
Completed and Signed Building Permit Application
Site/Plot Plan
If the site is not flat, show the topography
Legal description
Address
Lot size dimensions
Location on lot with distances to lot lines
Other structure locations and distances to
Sewer line location
Water line location
Driveway & parking pad location(s)
Stormwater location (i.e., downspouts, drywells, infiltration trenches, etc.)
All easement/street locations
Propane tank location, size, and distance to structures and lot line
Location of critical areas (if applicable)
Structural Plans
Elevations from all four directions
➢ Roof pitch
➢ Height of structure from grade
Foundation Plan
Floor Plan
➢ Door, window opening dimensions & egress
➢ Room identification
➢ Plumbing fixture locations
➢ Mechanical fixture locations
➢ Heating/Cooling equipment location
➢ Smoke & carbon monoxide location
Framing Plan
Roof Framing Plan
Structural cross sections & details
Department of Community Development
152 W Cedar St. Sequim, WA 98382
Phone: (360) 683-4908
www.sequimwa.gov
Business Hours: M - F, 7:30 am- 4:00 pm
10.
Page 2 of 2
Structural Calculations
Prescriptive
➢ Braced wall line locations and calculations for both seismic (D2) and wind (130 mph [Vult])
➢ Header & beam calculations
Engineered
➢ Plans stamped & signed by a professional architect or engineer
➢ Stamped & signed structural calculations
Energy Compliance
Residential worksheet with energy credits selected
Glazing schedule
Heating system sizing worksheet
Commercial worksheets, as applicable
Fees – may include, but are not limited to:
Site plan review
Plan review
Building permit
GFCs – water & sewer
Transportation impact
Parks impact
Building / Plumbing / Mechanical Permit Applicaon Permit No.________
152 W Cedar Street
phone 360-683-4908
fax 360-681-0552
www.sequimwa.gov
PROJECT LOCATION & DETAILS
Address__________________________________________
Geographic ID No. (Parcel #) _______________
Legal Descripon__________________________________________________________________________
Project Descripon ________________________________________________________________________
Accessory Dwelling Unit
Demolion
New Construcon
Sign Installaon
Addion
Fire Alarm/Sprinkler
Propane/Appliance
Tenant Improvement
Change of Use
Fire Suppression
Remodel/Replace/Repair
Wood/Pellet Stove
PROPERTY OWNER
Name___________________________________________________________________________________
Address_________________________________________________________________________________
City________________________________________________________ State_______ ZIP_____________
Phone____________________ Email__________________________________________________________
PROPOSED CONSTRUCTION
Stories________________ Units__________________
Bedrooms_____________ Bathrooms______________
1st Floor sq. ._________ 2nd Floor sq. .__________
Garage sq. . __________ Aached Detached
Carport sq. . __________ Aached Detached Labor Cost $__________________
Porch/deck sq. . _______ Covered Uncovered Materials Cost $__________________
Basement sq. . __________ Heated Unheated Total Cost $__________________
CONTRACTOR
Name___________________________________________________________________________________
Address_________________________________________________________________________________
City_________________________________________________________ State________ ZIP___________
Phone_____________________ Email________________________________________________________
State Business License No.________________ Exp. Date_____________
City Business License (UBI) No.____________ Exp. Date_____________
CONSTRUCTION FINANCING LENDER
Name___________________________________________________________________________________
Address_________________________________________________________________________________
City___________________________________________________________State_______ ZIP___________
Phone_______________________ Email______________________________________________________
Form updated 2/11/2020 Page 1 of 2
APPLICANT
Applicant Type:
Agent Architect Contractor Designer Engineer Owner Tenant Other__________________________
Name___________________________________________________________________________________
Address_________________________________________________________________________________
City________________________________________________________ State_______ ZIP_____________
Phone____________________ Email_________________________________________________________
11.
OFFICE USE ONLY
Building Approval: ________________________________________________________ Date_____________________________
Planning Approval: _______________________________________________________ Date_____________________________
Engineering Approval: _____________________________________________________ Date_____________________________
Cross Connecon Control Approval: __________________________________________ Date_____________________________
I hereby cerfy that the informaon provided is correct, that I am either the owner or authorized to act on behalf of the owner and that all acvies associated with
this permit will be in accordance with State laws and the City of Sequim Municipal Code. All sales tax paid to the State Dept. of Revenue on labor and materials used
for construcon with the Sequim City limits are to be reported under Locaon Code #0503. By signing below I agree to the applicable ulity charges which will begin
in 6 months or on the date of final inspecon, whichever comes first.
Owner/Agent Signature
_____________________________________________________________________________________
Date
___________________
Plumbing Fixtures
Quanty Quanty
Bathtub
Shower
Clothes Washer
Sink
Dishwasher
Toilet
Grease Trap
Urinal
Irrigaon System
Water Fountain
Sewer
Water Heater
Ulity Connecons
New Water Service
City PUD #1
Private Well Community Well
City Water Meter for Domesc
5/8” 1” 1-1/2” 2”
Irrigaon System? Yes No
If so, water supply from: City Ditch
If private or community well, is property located in
Dungeness Water Rule area? Yes No
(If yes, provide Migaon Cerficate from Washington Water Trust)
New Sewer Service
City Private Sepc Community Sepc
If City, on separate meter? Yes No
If Yes, what size?
5/8” 1” 1-1/2” 2”
Mechanical Fixtures
Air Handling Unit Heat Pump
Clothes Dryer Range Hood
Commercial HVAC
Unit
Venlaon Fan
Ductless Heat
Pump
Wall / Unit Heater
Fireplace/Stove/
Range
Propane Wood
Propane Tank (No. of Gallons)
Type of Heat
Project Address_____________________________
Permit No._________________________________
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Department of Community Development DESIGN REVIEW APPLICATION 152 (City of Sequim)

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Completed 19 January 2021

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