HomeMy WebLinkAboutBLD2004-00682 BUILDING PERMIT APPLICATIOI ML Review Type:
i
pe: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
EMIT #: BLD04-00682 Received Date: 10/26/2004
E ADDRESS: 233 NICKELBUSH LN
QUILCENE, 98376
/NER: JESSEFER GODSALVE PHONE: (360) 440-5304
SUZANNE L MARTIN
PO BOX 242
INDIANOLA WA 98342-0242
UBDIVISION: Block: Lot: T 4
'ARCEL NUMBER: 701061013 Section: 6 Township: 27 N Range: 01 W
CONTRACTOR: PHONE:
PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr NEW SFR W/ ATTACHED GAR & DECK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 120
VALUATION 79,487.00 ADD'L: 816 HEAT TYPE: OIL
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: 696 SHORELINE:
CONST TYPE: DECK: 84 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PWELL PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: 2 Prop: 2 Seismic Streams
Total: 2 Total: 2 Flood Way Floodplain
Routing Date: /0 / F&W Landslide
`a V1 Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $853.75 BAC 10/27/04 67893
Plan Check $554.94 BAC 10/27/04 67893
State Building Code $4.50 BAC 10/27/04 67893
Potable Water Application $52.00 BAC 10/27/04 67893
Total: $1,465.19
sow Jefferson County of Community Development
� ¢ , �al ` °� 0 621 Sheridan Street, ownsend WA 8836813601378-4458
Perm o ID o�� 1,' o - ci cQuo 0�
i,,,
xilding Type: 2 6 Project Type: Frame Type:
•
Single Family [AC New fg Wood
Garage Attached/Detached ❑ Addition ❑ Steel
1 Modular Li Alteration/Remodel ❑ Concrete
] Commercial -- - III Repair ❑ Masonry
i Multi-family/#of Units ❑ Demolition ❑ Other:
❑ Industrial
iliT , Ig Other: A0L'I
Bathrooms: Bedrooms: Type of Sewage Disposal: Type of Heat:
I(
' Choose one:
Existing: Existing: ❑ Sewer ❑ Community System ❑ Electricity l; Oil
Proposed: Z. Proposed: Z X Individual System
Total: Z Total: Z y El Woodstove ❑ Propane
If not sewer,fill out the following: Li Heat Pump
fill ❑ Conventional 14 Alternative CI Other
Permit# SEP a 3 -Cc ��
Water Supply:
[ A Private well ❑ Two Party Well L I Public:Name of water system:
Square Footage: Office Use o For Office Use Only
Main Floor .i Z. ) rli 833,(.4 V Consistency Review
2
.--
2ND Floor 81 b 5 .?�$• Base fee 3s,
3rd Floor Plan Check fee BSI, 9 '•
Htd Basement State Surcharge fee —j V' C)
Unhtd Basement Subtotal I ZI ((CA . 19
Garage/Carport 6C1b `61�0• Pot Water Review fee /� ^ CJ
QQ
Decks Oil - ":_1 � 911/Rd Approach fee T r\V cL
Commercial 1141
/ �q TOTAL l 5 4 go I.CI
(a
Industrial 1 Receipt# ((-1 .? 3
Other Cash/Check# 30 5 3
I 1 I(o 'It t-ca 5 I . H r e lao"()N
Initials
Date
Estimated Cost: / 1f CO/ 0 C C)
If within 200' of the Shoreline, N (
Distance to Bank or Ordinary High Water Mark ft.Bank Height ft.
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any
omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable 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 it's employees,representatives or agents for the purpose of application review and any required later inspections.
Access and right of entry to the a 'cant's prop or cture all be requested and shall occur during regular business hours.
Signature: � Date: /1(//0e
OVER ►
G:\PermitCenter\FORMS\BLDG FORMS\BLDPermit Application.doc 0l/08/2004
Z33 NICELBUSH LN BLD04-682—
GODSLAVE/MARTIN
Approvals Req'd Prior
to Final Inspection
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