HomeMy WebLinkAboutBLD2004-00498 •BUILDING PERMIT APPLICOION SEP87-00165
Jefferson County Department of Community Development Review Type: I
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00498 Received Date: 7/27/2004
SITE ADDRESS: 5500 WEST VALLEY RD
CHIMACUM, 98325
OWNER: CHARLES D NISBET
JUDY NISBET PHONE: (360) 732-4328
5500 W VALLEY RD
CHIMACUM WA 98325-9750
SUBDIVISION:
PARCEL NUMBER: 801044012 Block: Lot: +
Section: 4 Township: 28 N Range: 01 W
CONTRACTOR: ISLAND HAMMER LLC
PO BOX 2435 PHONE: (360) 697-9434
POULSBO WA 98370
Contractor's License ISLANHL015R9 Expires 12/29/2003
REPRESENTATIVE:
PHONE:
PROJECT DESCRIPTIOP RESIDENTIAL FIRE DAMAGE REPAIR - NO MLA REQ'D
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP REP
VALUATION 112,000.00 MAIN:
CODE EDITION: 2003 ADD'L: HEAT TYPE:
HEAT BASE: HEAT TYPE:
OCCUPANCY: R_3
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: 5-1HR OTHER:
CONST TYPE: GARAGE: SHORELINE:
DECK: SETBACK:
SEWAGE DISPOSAL: CON BANK HEIGHT:
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO
Bst: 3 STORMWATER: YES NO AREA
Exist: 2 Wetland
Prop: Prop: Erosion
Total: 3 Total: 2 Seismic Streams
Flood Way Floodplain
Routing Date: 7/02
7/1 F&W Landslide
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid Bv: Date: Receipt:
Permit $1,060.95 KAS 07/27/04 66623 AF4i,V F r
Plan Check $689.62 KAS 07/27/04 66623
State Building Code $4.50 KAS 07/27/04 66623 JUL Z 8 1004
Potable Water Application $52.00 KAS 07/27/04 66623
Jefferson County Plannir,
Total: $1,807.07
Wt�[� & Building pepartmens
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10° I
BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD04-00498
Received Date
CHIMACUM, 98325 07/27/2004
SITE ADDRESS: 5500 WEST VALLEY RD
Issue Date 07/28/2004
APPLICANT: CHARLES D NISBET
JUDY NISBET PHONE: (360) 732-4328
5500 W VALLEY RD
CHIMACUM WA 98325-9750
SUBDIVISION:
PARCEL NUMBER: 801044012 Block:
e:
Section: 4 Township: 28 N Ran Lot: +
CONTRACTOR: 9 01 W
ISLAND HAMMER LLC
PO BOX 2435 PHONE: (360) 697-9434
POULSBO WA 98370
Contractor's License: ISLANHL015R9 Expires: 12/31/2004
PROJECT DESCRIPTION: RESIDENTIAL FIRE DAMAGE REPAIR -NO MLA REQ'D
REQUIRED INSPECTIONS:
[ ] SETBACKS:
[ ] UFFER:
[ ] Footing:
[ ] Foundation:
[ ] Stormwater FINAL Approval:
[ l Underground Plumbing:
[ ] Underground Insulation:
[ ] Shear Wall :
[ ] Framing: , — L G
f 1 Plumbing: -1.1 `64
[ ] Propane Tank/Lines:
[ ] Insulation: Q�
f 1 Sheetrock:
f1 Septic Sytem Final Approval:
Road Approach Final Approval:
[ ] Zoning Final Approval:
f I Final/Occupancy Approval:
HEALTH DEPARTMENT AND PUBLIC WORKS 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 SCHEDU
Office Hours 9:00 a.m. -4:30 p.m. LE INSPECTIONS.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY-SEE REVERSE
SPECIAL CONDITIONS FOR gSE # BLD04-00498
1.) MUST SUBMIT WATER TEST: TOTAL COLIFORM/ NITRATE-N/CHLORIDE AND
WELL LOG BEFORE BUILDING PERMIT CAN BE FINALED
I:\F_BLD_Permit_Buildng.rpt
10/29/1999
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4� o JEFFERSOUNTY �. ,
i JUL
cr,� ' *I DEPARTMENT OF COMMUNITY DEVELOPMENT 2 ?�(}1
ti - ''4 621 Sheridan Street •• Port Townsend ••Washington 98368
360/379-4450 • 360/379-4451 Fax 1
O www.co.jefferson.wa.us/commdevelopment :PT. OF coiti i�vitii I r -'�
il&IfING�
MLA:
Master Permit Application
Project Description(include separate sheets as necessary):
I Li PropertyS (acres/square feet)
Tax Parcel80 Size:
Number: ,
Site Address and/or Directions to Property: ' /
Property Owner(, of Record_: ` Fax:I email:
��
Telephone: I OA ��
Mailing Address: t . �.� �� 'IA
(if different from owner): N I , entail: �' ` h'�''E`
AA - Fax: '
Telephone: . M •. :MK 0
Mailing Address:
What kind of Permit?(Check each box that applies)
❑Variance(Minor,Major or Reasonable Economic Use)
l l Building ❑ Conditional Use[C(a),C(d),or Cl**
❑ Demolition Familyon Permit ❑ Discretionary"D"or Unnamed Use Classification
❑ GarageigAttached
❑ Special Use(Essential Public Facilities)**
❑ Attached/Detached ❑ Boundary Line Adjustment
❑ Manufactured Home ❑ Short Plat**
❑ Co ❑ Binding Site Plan**
CI Commercial* ❑ Long Plat*"
❑ Change of Use l; Road Approach__ ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane roach______ ❑ Plat Vacation/Alteration**
0 Propane ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Allowed ter Management Use stency Analysis ❑ Shoreline Management Substantial Development**
❑ Stormwater
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
Comprehensive Plan/UDC/Land Use District Map Amendment
❑Temporary Use CI Jefferson County Shoreline Master Program Amendment
CI Wireless Telecommunication*
❑ Forest Practices Act/Release of Six-Year Moratorium **Re•wires a Pre-A••!;cation Conference
* Ma re•uire a Pre-A••lication Conference
Please identify any other local, state or federal permits required for this proposal, if known:
- DESIGNATION OF AGENT for permit(s).
1 l,._ 14c ..,.,,,,,,r,r 1.1.[- to act as my agent in matters relating to this application
I hereby designate J- S - / /q zee,
-3/1 c4� Date: ��rr✓
OWNER SIGNATURE
n,and in any attachments,is true and correct to
By signing this applicationwg form,Any he owner/agent attests that the information omiss on of a material fact maderovided 'by the owner/agent with respect to this application he best packet of
his,her or it's knowledge. Any material falsehood any
may result in this permit being null and void.
I further agree to save,indemnify nd hold against nst Jefferson County as aless Jefferson County result of orgainst all 'nb'lities,conseque9 consequence of the granting of this perinit,court costs,reasonable attorney's fees and
expenses which may in any way accrue9 County ,representatives orapplication
I furtheriewagree to provide ater i spend right Afccess and right of entry to Jefferson to this property sha and its llsbe requested and shall occur only •solering regular business
review and any required later i�i�pections 0 v
hours. Date: Miff v
Signature:
is
may
atively
or
nd action
or actions Applicant will undertake as a result of the issuance of mec es as those to ms ere impact
pon a one
e or amore
threat as he
endangered species and could lead to a potential"take"of an endangere sP that the actions that will be undertaken because this
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant
the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
permit has been issued will n iolate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered s ecies regarding your
with the ESA. The Applicant has read th' •i•calmer +r.6add fates it below.
action(s)even if you are in Pliance with
and non-transferable respo ilityfor adhering to and complying Date:
Signature:
i
GAP. enter ORMS\DRD FORMS\Master Pet Application 7-8-04.doc
• OWNER BUILDER STATEMENT
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that the are not licensed con
they will be assuming the responsibility of the General Contractor for the proposed project. y
Signature: tractors and that
Date:
GENERAL /'CONTRACTORL OR MANUFACTURED HOME INSTALLER:
�J l PHONE: FAX:
vv �,..AA ►.A.e r L.LC, (;Gv) , 57--I t13 K (360) 6,`l7-
MAILING ADDRESS: t_ q t s�
CONTRACTOR'S LICENSE , L( 3 $- UU S o ra 3�EMAIL: . ingmmin
r �i�,�.
NUMBER: WAINS
l$ 41014L0 SIZ,' NUMBER
ARCHITECT/ENGINEER:
MAILING ADDRESS: PHONE ( ) FAX:( )
EMAIL
Project Type: Frame Type:
❑ New Bathrooms: Shoreline: Type of Sewage Disposal:
❑ Addition Wood Existing:
Steel Proposed: Bank ; Sewer
J Alteration/Remodel ❑ Concrete Total: 0 Community System
i l Repair 0 Masonry Height: Il Individual System
i i Demolition ❑ Other: Bedrooms: SEP Permit#
Existing: '1 Water Supply:
Type of Heat: Proposed: Setback: Private well I 1 Two Party
<<r r c Total: I I Public
-- Name of System:
If this is a Commercial Project ou must answer the followin
Number of Parking Spaces: Current: roi :
Number of occupants(includes owners,tenants,employees,etc) Current Number of ADp Parking Spaces:
IBC Occupancy: IBC Type of construction: Proposed
Will you have
If this is a Pro are Tank and/or A fiance Installation rmit mark all items be ow that aFood.Service? Yes / No
i 1 Underground Tank I I Above ground Tank
I I Heat Stove 1 I Cook Stove 1 I Woodstove i Fireplace Inserte of Propane
Wat a r Tank 11 Pellet Stove f l Other
Is this a fiance bein 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
includin• the reserve area. p �Y
S•uare Foota•e For Office Use Only
IIIIIIIIIII
Main Floor Pro•osed
Amount
Mill
Consistency Review:
2 Floor
Mill3' Floor i�.
• Additional Section: llss
iiMpl
lailillill.11111_ Plan Check fee: /''
Heated Basement &NCI. (OvZ
State Surcharge fee:
Unheated Basement
,t.i_ Z Z Pot_ Water Review fee:
Other Unheated /a �)
1111111 911/Rd Approach fee:
Garage/Carport MI TOTAL: $
DecksIIIIIIIIIIII
Receipt Number:
Other /p��
Cash/Check Number: 1111111111111 l/.t^i '(
ESTIMATED COST(REQUIRED) g
\
•Fair market alue of all labor and materials foundation to finish Date:
��' I I �.. dop Initials: "ZS
G:\PermitCenter\FO'`"" '1P FORMSM p t Application 7-8-04.doc