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Home My WebLink AboutBLD2005-00125 •ILDING PERMIT APPLICATII MLRAOe 001129 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00125 Received Date: 3/3/2005 SITE ADDRESS: FLAGLER RD NORDLAND, 98358 OWNER: STATE OF WASHINGTON-NAT RESOUR , PHONE: PO BOX 47014 OLYMPIA WA 985047014 SUBDIVISION: Block: Lot: TX 1 PARCEL NUMBER: 021174000 Section: 17 Towns • 30 N Range: 01 E CONTRACTOR: MCCONNELL CONSTRUCTION S E.PHON 360-344-4102 194 PROTECTION RIDGE 'D PORT TOWNSEND WA 9 68 Contractor's License M ONC 0: - ' Expires 10/27/2 06 rc0 ). REPRESENTATIVE: HONE: J PROJECT DESCRIPTIOr NEW WATER TANK r -N 0 TYPE OF WORK UAR FOOTA E: TYPE OF IMP VALUATION 19,400. A N: CODE EDITION: 2003 D 'L: HEAT TYPE: OCCUPANCY: AT BAS HEAT TYPE: OCCUPANCY: NHEATED: # OF STORIES: CONST TYPE: OGARAGE: 0 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: 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 ,4'i )'$IJ 1'-`' /' Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,441.75 BAC 03/03/05 71538 Plan Check $937.14 BAC 03/03/05 71538 State Building Code $4.50 BAC 03/03/05 71538 Total: $2,383.39 ��gg ' ,�oly co�,��,� JDEPARTMEEFFERSON OF cNTY NT COMMUNITY DEVELOPMENT K1 621 Sheridan Street• Port Tc}wnsend_• yasbington 9836$.,..___ 360/379-4450 • 360/379-445�1 Fax ii . 44iii gs, NG�p www.co.jefferson.wa.us/com�ndevopment _ `� i l Master Permit Application MAR - 3 2005 'M, 4 C 5 I a( Project Description(include separate P sheets as necessary): • Tax Parcel i Property - Number: 0;2 fl7 Size: .5' 3 hie (acres/square feet) Site Address and/or Directions to Property: > , /9e-Ze '= jX-Art prnr/ - A99A7�/c/.17i,C � Property Owner(s)of Record: _57ji7I L'>/ 2i� ill. //,1/517W , i',E-/ / /e(U -S Telephone: Fax: email: Mailing Address: X '/7&//` (22 t'/1774//L 1// /1-- `g5e,9 7e'/lf Applicant/Agent(if different from owner): Z f A/Af(LL et7A):I;7tre m/? ,V Telephone: 3&P—3 `."',/eV Fax: e2 — 3-Y - - /C9!� email: /CE'0 0/opeN, "4/ Mailing Address: / 74 f R'Ot-t-e-' ie7,4/ Rt'J'/-F RP .Pne fi/1i410--)Cii-"i'r' 9;031-A. What kind of Permit?(Check each box that applies) ❑ Building ❑ Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** ❑Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑Garage Attached/Detached ❑ Special Use(Essential Public Facilities)'" ❑ Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat-- p'Commercial* ' ❑ Binding Site Plan** ❑Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ 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: 571"",cEl.MVt 5 _ 7"147 to '%'/ Z*- Pi-1/ 2L. f "ff,,-'f r i'ei/ `" DESIGNATION OF AGENT I hereby designate" 2, !'t7CC'/7A14/2=L,� to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE At.../21---" , k',p�2e. Date: , /4' Z c9e, �� 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 inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: . Date: :''.. ' 5 —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 the Jefferson County development ccde.The Applicant acknowledges that he,she or it holds individual and non-transferable responsibility for adheri d complyin • ESA. The Applicant has read this disclaimer and signs and dates it below. Signature:_-.%`7 ` Date: .2 — ` e--51-. G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 9hereby • OWNER BUILDER STATEMENT • c/ �iV�0 The signer of this statement does certify thatthey are the Owners of the parcel referenced herein,that they are not licensed con't adore i615153t they will be assuming the responsibility of the General Contractor for the proposed project 'I V/fit' Signature: Date: °gIOI7 Q rt �7 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: '. l%.'C0/ A'E4 /1-1 /��kt � 1 P (= C- ) 3,7#-i'/9/ ( 39 " Z ) - �- MAILING ADDRESS: /7,1L'1 ,y�4'�114," l I.b 6. I,h . EMAIL: A442 V e,,//pair✓, 7:29,4 CONTRACTOR'S LICENSE rc'', '7 ` i7PC"--"Sr/iV 7fi'3,bos WAINS NUMBER: ove,'&/)? 06 3if A- NUMBER ARCHITECT/ENGINEER: r19,09 'iI-/ k/ zy�� PHONE (_360)e.` 15.7 FAX:(34,,> 7 14-7 f MAILING ADDRESS: 71i19/0J:si�¢� ko¢9' ,5-4�fr ; ' L. EMAIL 14,46,,,-G' YgLr ix , "ice R r7,- f Age iiiik ei :141. =7-;`1` Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: O�New ❑ Wood Existing: ❑ Sewer ❑ Addition El Steel ProposedBank ❑ Community System ❑ Alteration/Remodel eConcrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# _ ❑ Demolition ❑ Other: Bedrooms:/ Water Supply: ��titer ResePL J ib(` Existing:, Setback: ❑ Private well ❑ Two Party Type o ye at: Proposed: public / Total: Name of System: If this is a Commercial Proiect you must answer the following: Alumber of Parking Spaces: Current OF Proposed: " Number of ADA Parking Space : S Number of occupants(includes owners,tenants,employees,etc) Current Proposed c" IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes o 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 ❑ 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 For Office Use Only "' Currerre Proposed Amount - Main Floor _. Cons ncy Review: 4 et .00 2ND Floor ".- [ .f t "ci, i[� V Floor I ieil -_____ �� Addition' Section: .---- Mezzanine: --3 ,-305 ,, . Mezzanine: I Plan Check fee: n 37 . 14 Heated Basement ` State Surcharge fee: `� Unheated Basement Pot Water Review fee: Other Unheated 911/Rd Approach fee: Garage/Carport TOTAL: $ 2432. - " t Decks Receipt Number: 1 r Other Cash/Check Number: , • wf1F ' 1' r�/( 707 - i ESTIMATED COST(REQUIRED) Date: �) .Fair ma et value of all labor and materials foundation to finish gt «"l " 0 Initials: 1 �,__ ter. f G:\PemutCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc