HomeMy WebLinkAboutBLD2005-00071 •UILDING PERMIT APPLICA•N B RDOe 00071
Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00071 Received Date: 2/9/2005
SITE ADDRESS: 270 DISNEY RD
NORDLAND, 98358
OWNER: LISA S PETRICK PHONE:
GARRON J PETRICK JR
PO BOX 900
PORT HADLOCK WA 983390900
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 921094009 Section: 9 Township: 29 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr REMODEL - NO CHG IN FOOTPRINT
NO MLA REQRD
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP ALT MAIN:
VALUATION 48,000.00 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:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
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
Routing Date: F&W Landslide
� S .oc' � Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $633.65 BAC 02/09/05 71339 APPROVED
Plan Check $411.68 BAC 02/09/05 71339
State Building Code $4.50 BAC 02/09/05 71339 FEB - 9 2005
Total: $1,049.83
Jefferson County Planning
&Bu'din, Department
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JEFFERSON COUNTY DO
• BUILDING PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00071 Received Date 02/9/2005
SITE ADDRESS: 270 DISNEY RD Issue Date 02/10/2005
NORDLAND, 98358
APPLICANT: LISA S PETRICK PHONE:
GARRON J PETRICK JR
PO BOX 900
PORT HADLOCK WA 983390900
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 921094009 Section: 9 Township: 29 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
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PROJECT DESCRIPTION() EMODEL - NO CHG IN FOOTPRINT
NO MLA REQRD
CALL IN FOR THE REQUI Q INSPECTIONS THAT APPLY TO YOUR PROJECT.
SETBACKS: //A
UFFER:
:: ion:
Stormwater FI L Ap
Un.ergroun. ' u . • g: (Cr/a-
Undrground Insulation:.
hear Wall• , fy s
r ming: ) 6X 5/( aS,
Plumbing: N/A..
Propane Tank/ Lines: 1 /A- /.urERda�- �lt„pA,us- Lugs
nsulatio CC.)K 3/z2.as
heetrocc 0�' 3/z 4//ds f'
Septic bytem Final Approval (If not on sewer): tj r4
Road Approach Final Approval: VA
Zoning Final Approval: A
nal/Occupancy Approval.> ) 1-
r'
r
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 SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
PERMIT # BM
0 5 - 007 1
I:\F_BLD_Permit_Buildng.rpt 10/29/19
JEFFERSON COUNTY BCD
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��¢SONr °or, JEFFERSOOUNTY ' �'? y
' �' DEPARTMENT OF COMMUNITY DEVELOPMENT
�' 621 Sheridan Street • Port Townsend •Washington 98368 FEB 9 2004 J
360/379-4450 • 360/379-4451 Fax
kgs 0. ' www.co.jefferson.wa.us/commdevelopment ,
HIND JEFFERSON COUNTY
^FPT. OF COMMUNITY DEVELOPMENT s
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
Tax Parcel Property Number: 9
z I 0 f Lf (J 9 (�
0 Size: J , 6 4-C i'Zt (acres/square feet)
Site Address and/or Directions to Property: a7p ` ;sh,e Kc,,L) tj4 fdl L cQ WA-
Property Owner(s)of Record: : k:2 zCC Nora,Ni L i�r- -"ea-T,z lc i- '7
Telephone: `; t'0 -' icy- Sy 2"2, Fax: .36C>- S.i"S-3 3tl / email:
Mailing Address: T J il- o x. c-Aci0 .�2 t-- N441esc k Wp.- v, $ 7---S5
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
I i Building ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit Li Conditional Use[C(a),C(d),or C]**
•f'Single Family '- -y ( ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
0 Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat--
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use ❑ Long Plat**
❑Address i-i 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
❑ 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 4. ''`��`f V�"j�c� _to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE L. �--t�'a� r��i-�7- Date: " 7_G S
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 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 later inspecticlps Access and right of entry to this property shall be requested and shall occur only during regular business
hours.' !// `
Signs �•' Date: __' — c }
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 th Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable ponsibilit�for adheri and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signa t Z—.- ' Date: - `i c
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
IIOWNER BUILDER STATEMENT 411,
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 assumi e respons' '''' the
I Contractor for the proposed project.
Signatur '^-c t/ c Date: 2• - ^ CIS
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: \. A WAINS
EMAIL:
CONTRACTOR'S LICENSE \►
1, 9 2004
NUMBER: ►` Uv,, FEB NUMBER
ARCHITECT/ENGINEER: l� PHONE ( ) FAX:( )
MAILING ADDRESS: t .3V-ri: EMAIL
Project Type: \F ame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
Cl New �( Wood Existing: ❑ Sewer
❑ Addition _-___ ❑\Steel Proposed: Bank ❑ Cpmmunity System
_ ►Iteration/Remodel_ ❑ Concrete To Height: Individual System
❑. Ir t ❑ Masonry (� SEP Permit#
Bedrooms. V Water Supply:
0 Demolition [1 Other: / PP Y
Existing: Setback: ,_Private well L1 Two Party
Type of Heat: Proposed:Total: 0 Public
Total: 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:
U Underground Tank [1 Above ground Tank Size of Propane Tank:
Ii Heat Stove Cl Cook Stove C1 Woodstove Li Fireplace Insert I7 Hot Water Tank Ll Pellet Stove Li 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: ---.
2N1)Floor Base fee:-
cJ,
3`d Floor Additional Section:
C
Mezzanine: Plan Check fee: , A I b ir
Heated Basement J State Surcharge fee: ��.\
o V
Unheated Basement ) V Pot Water Review fee:
L
Other Unheated . 911/Rd Approach fee:
Garage/Carport 1O,
TOTAL: $ `+O (i .3
Decks 1
Receipt Number: ] 3 3`—
Other Cash/Check Number: ,
ESTIMATED COST(REQUIRED) Date: c: j�
.Fair market value of all labor and materials foundation to finish cJ�
zi-ci5 C.x Initials: C.—
G:\PermitCenter\FORMS\DR)FORMS\Master Permit Application 7-8-04.doc