HomeMy WebLinkAboutBLD2004-00606 • • M LA04-00566
Review Type: I
MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00606 Received Date: 9/27/2004
SITE ADDRESS: 317 PORT HADLOCK HEIGHTS RD
PORT HADLOCK, 98339
APPLICANT: BRODERS INC PHONE: (360) 797-7722
4503 OLD GARDINER RD
PORT TOWNSEND WA 98368
SUBDIVISION: PORT HADLOCK HEIGHTS MH PARK Block: Lot:
PARCEL NUMBER: 989500001 Section: 11 Township: 29 N Range: 01 W
CONTRACTOR/ MIKE MEINBERG PHONE:
DEALER:
Contractor's License WAINS0098 Expires 7/31/2004
INSTALLER: MIKE MEINBERG WAINS0098 7/31/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION: NEW MFH (LOT 33)
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: GOLDENWEST SETBACK:
VALUATION 95,000.00 YEAR: 2003
LABOR& INDUSTRIES APPROVAL?
SIZE: 66 X 41 BANK HEIGHT:
SEWAGE DISPOSAL: CMY
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO
STORMWATER: YES NO
Exist: Exist: AREA Plat Conditions
Prop: 3 Prop: 2 Wetland Erosion
Total: 3 Total: 2 Seismic Streams
Flood Way Floodplain
Routing Date: i f Z1 I ' t c n_ F&W Landslide
�_�'��J Shoreline Aquifer
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $154.00 KAS 09/27/04 67764
Add. Manufactured Home $32.00 KAS 09/27/04 67764
Potable Water Application $52.00 KAS 09/27/04 67764
Total: $238.00
AEFFERSON COUNTY ASSESSOR
JACK WESTESAN III
ASSESSOR JEFFERSON COUNTY COURTHOUSE
PO BOX 1220, PORT TOWNSEND WA 98368
(360) 385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME / MAILING ADDRESS:
THIS IS NOT A TAX STATEMENT
NAME: To/sA 81 S C H E L
The purpose of this questionnaire is to obtain information
regarding either the current location of a mobile home or the
ADDRESS: Jr�iG g�}`( S T
previous ownership and location of a mobile home. This will
�r�I,LS go t" (� ci$3 help our office determine whether the mobile home is already
on the tax rolls in Jefferson County or if it has been moved to
TELEPHONE NO: 360-- 7 7— 5711 l this county frpm another area. Please see reverse side for
additional information.
1) MOBILE HOME DATA:1
(A) MAKE Go L dew J t s4- (B) MODEL G E CC 5 K
� (C) YEAR .LUa
(D) LENGTH 6 6 /// rl
(E) WIDTH -10 b (F)SERIAL NUMBER
(G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) li CI. S, E ci (H) PURCHASE DATE pf zoe
2) PREVIOUS OWNER / LOCATION OF MOBILE HOME:
(A) FROM WHOM DID YOU PURCHASE MOBILE
ADDRESS
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES NO (IF NO, WHAT COUNTY?
IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE?
3) WHERE MOBILE HOME IS TO BE LOCATED: SEP 2 7 2004
(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? 'ES NO
(B) IF LOCATED IN A MOBILE HOME PARK:
NAME B&ADDRESS OFPARK I- 0 oc(1 He,ak4-S SPA
SPACE NO. 33
(C) IF NOT LOCATED IN A MOBILE HOME PARK:
NAME OF LAND OWNER:
LOCATION (ADDRESS)
REAL PROPERTY PARCEL NUMBER/DESCRIPTION
THANK YOU FOR YOUR HELP! 3Z-o-ytev2) 6.01/(
SIGNATURE
KELLI LARSON, roperty Technician
THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION.
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o6 JEFFERSON JNTY1-,111r144, ,1,
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DEPARTMENT OF COMMUNITY DEVELOPMENT 1 i ` " # ,
;1 i Ep 2 7 2004 ,:-'
S 621 Sheridan Street- Port Townsend •Washington 98368 :!:l !
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360/379-4450 • 360/379-4451 Fax ! _
kys 0� www.co.Jefferson.wa.us/commdevelopment 1 l~-
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Master Permit Application MLA: (J�'l� �S�l�
Project Description(include separate sheets as necessary):
Z/vS"TA-if ' F G. HonrtE
Tax Parcel Property
Number: ci 2
8 9 $Do 0 0 / Size: /0� S 6 8 / (acres/square feet)
Site Address and/or Directions to Property: 317 Po,.-/- PA..l/.c 4 hit-1:g A�s R o A.S
Property Owner(s)of Record: 53Ro6ERs /Nc (L4)1 d 1 / T oM B1 s<Ht:1, (A a b!l)
Telephone: 3 66 7 q 7 772.2 Fax: 360 7a 7 7/ 3 3
MailingAddress: 4 5 0 3 email:
old Gc���nr� Rc], pi%, i g368'
Applicant/Agent(if different from owner): `41W $3gr)iatt: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 0 Conditional Use[C(a),C(d),or C]**
❑Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached ❑Special Use(Essential Public Facilities)**
X Manufactured Home 0 Boundary Line Adjustment
0 Modular ❑ Short Plat**
❑Commercial* 0 Binding Site Plan**
❑Change of Use 0 Long Plat**
❑Address ❑ Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
0 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 R I C I-f A R D .2 0 D&RS to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATUREI
�[� Q Date: 7 —/4‘— D
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 attomey'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 laterte inspections.Access a right Of en is pr shall be requested and shall occur only during regular business
hours. � '�"' K 4--ei t
Signature. ,�. Date: 7--/(—o y
The action or actions Applicant will undertake 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-transf` ponsi ility f�adhering to and g E . The plicant has read this disclaimer and signs and dates it below.
Signature: ��,, Date: `)—16`
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
OWNER BUILDER STATEMENT
The signer of this statement does hereby certify that re the Owners of the parcel referenced herein a[}Olt ensed cpry 6tols fat
they will be assuming the responsibility of the General tractor for the proposed project. i t I ! - _ti _ ,`+ : !i
Signature: Date: ! (� ,ti 1
lit t'
SEP 2 7 7(�]/�. ' i-
1.:I
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: 4FAX_:
MIkF M EIN8E G ( ) ; JE I(I1tU ITV'
MAILING ADDRESS: EMAIL:
• prPi. Of C-Oly ki'AI C'
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER D O a s (7_ 3/_p S )
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New ❑ Wood Existing: ❑ Sewer
O Addition ❑ Steel Proposed: 2 Bank X.Community System
O Alteration/Remodel ❑ Concrete Total: -----rr— Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: X Public
Total. 3 Name of System: f U I)—
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 ❑ Above ground Tank Size of Propane Tank:
❑ Heat Stove ❑ Cook Stove 0 Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ 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 IFOrDfice1 y :<�r t
Current Proposed . • x "`�`} O-I
q 1 � j`�471f rs�w` t�
Main Floor ,. #ZeneiM • c r a .z97 ,
2""Floor
•
3°Floor :Additional Section: x -
Mezzanine: Plan Ct eckfee: /• r` s< . < �. _r
Heated Basement Mate
y l j i
Unheated Basement Pot Water Revllew a �- y `y
r
Other Unheated • • � qa
Garage/Carport < TCI~> v{ fi , "`
Decks olot,.Numbot7 : . it f f , , ", . "r
Other I`:ashlC lC u '•..: ii 4' c vn-j,2n 6
ESTIMATED COST REQUIRED � T'N
( ) - .. tiii � c r� 4 k s
•Fair market value of all labor and materials foundation to finish y ttilyy• ,', '' •"y , .. ,
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