HomeMy WebLinkAboutBLD2004-00760 4111UILDING PERMIT APPLICATi'GN MLA04-00671
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00760 Received Date: 12/2/2004
SITE ADDRESS: 23(YIOLD FERRY RD
PORT HADLOCK, 98339
OWNER: DANA A STOCKS PHONE: (425) 891-4048
RICHARD A STOCKS
9550 172ND AVE NE
REDMOND WA 98052-3229
SUBDIVISION: PORTAGE BAY PARK Block: Lot: 12-14
PARCEL NUMBER: 989100011 Section: 1 Township: 29 N Range: 01 W
CONTRACTOR: CORY MEDEIROS M V BUILDERS PHONE: (360)6611721
3395 OLD HWY 99
BURLINGTON WA 98233
REPRESENTATIVE: CORY MEDEIROS PHONE: (360) 661-1721
PROJECT DESCRIPTIOP ADU
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP ADU MAIN: 528
VALUATION 34,468.00 ADD'L: HEAT TYPE:
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK: 150
BANK HEIGHT: 50
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: 0 Exist: Wetland Erosion
Prop: 1 Prop: 1 Seismic Streams
Total: 1 Total: 1 Flood Way Floodplain
Routing Date: i -, / < p.., F&W Landslide
X i Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $492.25 BAC 12/02/04 68736
Plan Check $319.97 BAC 12/02/04 68736
State Building Code $4.50 BAC 12/02/04 68736
Total: $816.72
ill
,�,11,7N cow JEFFERSONtUNTY
o
' 14;4,4 DEPARTMENT OF COMMUNITY DEVELOPMENT '
621 Sheridan Street• Port Townsend •Washington 98368 1'
360/379-4450 • 360/379-4451 Fax
4.�qs0� www.co.jefferson.wa.us/commdevelopment DEC - 2 2004
Master Permit Application — (.0
MLA:- ,
0
Project Ilk,--;.,+•ten(include separate sheets as necessary): • --_
, /no C( / ,230 o l/ Fri.^y 14 P ^-/-
Tax Parcel °' EI``d "k , tut, Fir R'-�•Sto ck4
P
Number: 9 'i/ b o O / I -1 8 (acres/square feet)
Site Address and/or Directions to Property: a 30 v ld Ferry 14S , /crf iht c/L c k • co A
Property Owner(s)of Record: R"ict a r d t"0, *,9 S c;e_ks
Telephone: 61S) 39/-SI098 Fax email: 14Aa.SA.)c,/fs e/hsd.Cain
Mailing Address: a 3 o old Peery R d. 1°E,r/ //ac✓/c'c k ,, (tlg 913.99-c21,2,
Applicant/Agent(if different from owner):
Telephone: Fax email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑ Building 0 Variance(Minor,Major or Reasonable Economic Use)
D Demolition Permit 0 Conditional Use[C(a),C(d),or CJ**
*Single-Family f}`b L( 0 Discretionary`Cr or Unnamed Use Classification
❑Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
I Manufactured Home 0 Boundary Line Adjustment )
❑Modular 0 Short Plat**
❑Commercial* D Binding Site Plan**
0 Change of Use D Long Plat**
❑Address D Road Approach 0 Planned Rural Residential Development(PRRD?/Amendments**
❑Propane ❑ Plat Vacation/Alteration**
❑Allowed'Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
D Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
D Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑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:
I herebyHate E y s DESIGNATION OF AGENT
designate- o�P%R to act as my agent in matters relating to th' application for permit(s).
OWNER SIGNATURE r
Date: // t✓ of
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 review and any required later inspections. purpose businessf sstion
hours. Acrpss and ' t of entry to this property shall be requested and shall occur only during regular
Signature: >' ,/ c l'� I I� /3h4/
Date: ////2/2 e aY
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 you are in compliance with the Jefferson County
and non-trensferabl development p code.The Applicant acknowledges that he,she or it holds individual
ability for adhering to and complying with the ESA. The Applicant has read this disdai r and signs and dates it below.
Signature: .,t om , S')� cL. Date: r
K ll/L 1-.0 / ✓ /7--/O/arOil G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENTill
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
!nV A /(160 �y /2/eoe, o 4 ( .9 o) 7-2`/ - 09f5 3 ( )
MAILING ADDRESS: EMAIL:
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
I
3 3 S� O/J f4,7 ffh./ PHONE ( ) FAX:( )
MAILING ADDRESS: Aid/ `7� LU/} 'Es'423 3 EMAIL _
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: / Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: I Height: A Individual System
❑ Repair ❑ Masonry Sa S P Permit# D'7` //G°
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well ❑ Two Party
Type of Heat: Proposed: 1 rK Public
Total: 1 /5° Name of System:
If this is a Commercial Prolect 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 0 Cook Stove 0 Woodstove 0 Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove 0 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 ei 1 e'Use Only "' '' '' �$�"`� Y `'
Current Proposed �j ':.kit.:-. 4 ,: i i .,, i
Main Floor ,3 l r. 'ns r yRe �'E , 1 ;; t
t ,�'G V �'at '4
NU ''' - am,'. r ,
2 Floor It.. .�as � i t . Y
3f0 Floor " idrtlonatectton lc 34 ti ,j .}&,
Mezzanine: r t' '�Plan'.Checkfee. . ,.` y tk R .4- ,� . ,r � 4 r s,
,.+F,:tisj,.a s� 1 Z; y.'S `� 0 1'S t
Heated Basement State Surcharges '`s ; .',',w , 1,44.. ' 4,4 4,:�; _ w
DEC - ;} A .,,X : }n a ', f �' "M' �n •g s F
Unheated Basement4,4
' Pot Water z,041 a �M i' `d m,�g��� i -�w r ., 's1
s r.. a,, be `' -, ai
Other Unheated 911/Rd � ,. ''� `: C• iA �
Garage/Carport TO � ;<d { .11 '�•°, '` ` a
,�� vl X • 4 4 JJiro- :i
Deck$ 1 -e, 4y ap4* ' . s tM '»+ s ' l-.•. 4.
Other • Cash/Cho4K+1u `` a" :
ESTIMATED COST(REQUIRED) Date: �, " " �} ,` , 0 " ;,'i
*Fair mark value of all labor and materials foundation to finish ' trtw v .-"zt A F� .,. ¢ 74
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