HomeMy WebLinkAboutBLD2004-00463 Ilk
UILDING PERMIT APPLICAtN MLA04-00427
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD04-00463 Received Date: 7/9/2004
SITE ADDRESS: 372 RHODODENDRON LN
BRINNON, 98320
OWNER: DAVE RALPH PHONE: (253) 606-6987
RHONDA RALPH
13510 SE 301 ST
AUBURN WA 98092
SUBDIVISION: Block: Lot: T 63+
PARCEL NUMBER: 502151017 Section: 15 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI FOUNDATION ONLY
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 5,000.00 ADD'L: HEAT TYPE:
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY:
CONST TYPE: OTHER: 528 SHORELINE:
CONST TYPE: GARAGE: SETBACK: 220
DECK: BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PARCEL TAGS: YES_ NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Floodplain
F&W Landslide
Routing Date:
. (cl 'ry cK Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $125.25 KAS 07/08/04 66476
Plan Check $81.41 KAS 07/08/04 66476
State Building Code $4.50 KAS 07/08/04 66476
Total: $211.16
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DEPT.OF COMMUNITY DEVELOPMENT
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APPROVED-
-SITE PLAN
MAY 3 I 2006 c___00_,;./ LA.,..)71...?"--il
5 -1 Z b —(I 5 DEPT. OF COM�UN TY DEVELOPMENT
��, ON eG� JEFFERSOI UNTY r ! I k,a ` T F 1 n .s
'� `A DEPARTMENT OF COMMUNITY DEVELOPMENT i i r",.., , Li)
I` '4 621 Sheridan Street• Port Townsend •Washington 98368 � ! JUL — 8 2004
__.�.,,.�c. 360/379-4450 • 360/379-4451 Fax I
�gS� , O� www.co.jefferson.wa.us/commdevelopment �- i
RING JEFFEFSD' COUNTY
LEFT. OF COMIVG ITY DF\'ELOPMEN'T
Master Permit Application MLA':""
Project Description(include separate sheets as necessary): •
1 ax a I ) /Property7
(
Number: /57 )- 0/ Size:
/ / /.i/cv (acres/square feet)
Site Address and/or Directions to PPrpperty: -..5/7 �„ ,6r z,1-,y,_„ ; ' yL f. L. 2,15
Property Owner(s)of Record: AFA.4 ,L d- „... n,4
Telephone: 5;J) £%O6 ‘'97 7 Fax:.9 726 - Ct 7)-- email: ,
Mailing Address:/, 57D ,, 7/ /y..w,-, L 't-f2%yd—.
Applicant/Agent(if different from owner): ,t,%/f
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Building ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
0 Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
❑Change of Use ❑ Long Plat**
❑Address Li Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments**
Cl Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions*"
0 Stormwater Management ❑ Shoreline Management Substantial Development**
0 Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
l i Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
LI Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre—Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in 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 provi access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any req(ired la r inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: L___-----"<:—1./1 i--✓ 1 i Date: ./..1/ i/
The action or actions Applicant will 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 y n compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfer ble r onssibility for adhering to and complying with the ESA. The Applicant has read this disdai er nd signs and dates it below.
Signature: ( e.i L 1. - Date: 7 ,j- 0 '7
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT
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The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that rney are not licensed contracter tit t
they will be assu�ng the r possibility of the Ggneral Contractor for the proposed project, j I I i r v f
Signature: C r=.,-jL-----I, l Date: / "' O / " I
. _ — ,
— &
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: Jul
tt
MAILING ADDRESS: EMAIL: ' `. ,.r"�;i pp,.•c; i
CONTRACTOR'S LICENSE WAINS . .. .. . -
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: I, Shoreline: Type of Sewage Disposal:
G"New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ®'`Concrete Total: Height: 0 Individual System
❑ Repair 0 Masonry SEP Permit#
O Demolition ❑ Other: Bedrooms: ti i xWater Supply:
Existing: w Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ( ❑ Public
Total: ' -1C rf Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
Underground Tank [I Above ground Tank Size of Propane Tank:
11 Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert [7 Hot Water Tank [1 Pellet Stove [] Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines,tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only * -,
Current Proposed Amount ,:
Main Floor Consistency Review: l ,
2Nu Floor Base fee:
3f0 Floor Additional Section: �1-1
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee: et
Garage/Carport
TOTAL: $ 5q• j k.
Decks Receipt Number. Ix:(,L17 -
Othe i i Cash/Check Number:
. �1
ESTIMATED COST(REQUIRED) ` Date: 1
.Fair market value of all labor and materials foundation to finish '7( Cl C. Cf
:-. Z� �'. Initials: 62(Z,��,
G:\PemritCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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