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HomeMy WebLinkAboutBLD2006-006731 • 1=• BLD06-00673 JILDING PERMIT APPLICATION Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00673 Received Date: 11/30/2006 SITE ADDRESS: 255 LILLIAN ST CHIMACUM, 98325 OWNER: ROBYN L HIRSCHEL PHONE: MATT MIDDLETON PO BOX 174 PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901101022 Section: 10 Township: 29 N Range: 01 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION TITLE ELIMINATION TYPE OF WORK T.E SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION MAIN: CODE EDITION: 1976 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total:rRouting Date: Type Amount Paid Bv: Date: Receipt: Approved/Date Manufactured Homes $163.00 CJZ 11/30/06 85292 Total: $163.00 0 • MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Departmert of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD06-00673 Received Date: 11/30/2006 SITE ADDRESS: 255 LILLIAN ST Issue Date: 11/30/2006 CHIMACUM, 98325 APPLICANT: ROBYN L HIRSCHEL MATT MIDDLETON PO BOX 174 PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: PARCEL#: 901101022 Section: 10 Township: 29 N Range: 01 W CONTRACTOR/ DEALER PROJECT DESCRIPTION: TITLE ELIMINATION MAKE: BAYFRONT YEAR: 1976 SIZE: 14X68 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 11/30/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): Stormwater FINAL Approval: Blocking/Plumbing: Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: it-�O O -- HEALTH DEPARTMENT AND PUB IC 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 44��„gON C"0 JEFFERSONSUNTY • W y� ,� DEPARTMENT OF COMMUNITY DEVELOPMENT '' ;:� `4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax qs p www.co.jeffers• 360/ 79-44 mdevelopment Master Permit Application MLA: ND -. O L.� R.--en :(34-11 Project Description(include separate sheets as necessary): 1 ca‘Yll)1 v-ALAto l — l idw' -- Tax Parcel ( \ _ ••- y Number: CI(`, ` �. l CI l_ e: . l �y (acres/square feet) Site Address and/or Directions toroperty: a 5 ( _t<I t L1/4 V S` Property Owner(s)of Record: v .��l 1� l i/r�( lit'R 1 {C( - (,A (ski ft itly) N Telephone: . .Q 301"Z((:�(% - 37 -(.� t_p -1 email: Mailing Address: t { (2"�is 1-1 L1 �-thwyt L Ck (.C:L.if U .L-C_ CI' %'3 C' Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) i Building i Variance(Minor, Major or Reasonable Economic Use) i Demolition Permit I Conditional Use[C(a), C(d), or C]** i Single Family I D scretionary"D"or Unnamed Use Classification i Garage Attached/Detached I Special Use(Essential Public Facilities)** f Manufactured Home i Boundary Line Adjustment I Modular i Short Plat** 1 Commercial* i Binding Site Plan** i Change of Use i Long Plat** I Address 1 Road Approach i Planned Rural Residential Development(PRRD)/Amendments** i Propane 1 Plat Vacation/Alteration** Allowed"Yes"Use Consistency Analysis i Shoreline Master Program Exemption/Permit Revisions** I Stormwater Management i Shoreline Management Substantial Development** i Site Plan Approval Advance Determination(SPAAD)* I Shoreline Management Variance i Temporary Use 1 Comprehensive Plan/UDC/Land Use District Map Amendment i Wireless Telecommunication* i Jefferson County Shoreline Master Program Amendment i 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 to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: 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. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the a p ti n that he or sh tnts prior n tiice. Signature: l v loi Date: \ ( i ? i / C U 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 compliapce with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-tra rable s i ilit 1 r *n to and complying with the ESA. The Applicant has read this disclaim and igns.and dates it below. Signature:1 L Date: /I Y G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc • BUILDER STATEMENT • 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: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New ❑ Wood Existing: a Sewer ❑ Addition 0 Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: II Private well I I Two Party Type of Heat: Proposed: i Public Total: Name of System: If this is a Commercial Protect 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 i Woodstove i 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 Current Proposed For Office Use Only Amount Revision Main Floor Heated EH Bld App Review: "a Floor Heated Consistency Review: Other Heated Base fee: ( ` Mezzanine Additional Section: (0 Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: Other TOTAL: $ `�O Receipt Number: Cash/Check Number: ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish Initials: G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc • • RETURN ADDRESS I(7 STATFOFWASHINGTON MANUFACTURED HOME ' PLEASE'CHECK ONE L4�U=a.lruntof [TITLE ELIMINATION IICEflSIflG APPLICATION ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ['REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YE0471- (WE LE GTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) LAND i� t NO. 0 j� � XII LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE AAFFIXED 0 REMOVED REgC4t/ rTyTOPtRCUOt)A2 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE lUn[QI tEPrTIQN 0 © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE W COUilT(NUMBER NUMBER 0 GISTERED OWNERS NUMBER I F LEGAL OWNERS E REGISTE^RED,(1�WNER DOL CUSTOMER ACCOUNT NUMBER \--\\ D TV l., DOWN QsIt\IKI OF DOL CUSTOMER ACCOUNT NUMBER ,.,fR SS .1 n\4 CITY STATE ZIP CODE NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER 3,Y t\S 0..,re-A-0 na.I('.1CO NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE GRANTEE NAME AM/ARE DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE /ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: �r '\Signature of Registered Owner and Title, IF APPLICABLE `+ `, Signature of Adtht n"�al Registered Owner and Title, IF APPLICABLE �1 k. N0Tz4� ItoRp, ktii,1'1'"' I NOTARIZATION/CERTIFICATI FOR REGISTERED OW ER(S)SIGNATURE OQ'NN" SIOi t'* h State of Washington / Signed or attested �^_ Oil before me on QCC1 V �,� kF+A?�� County of--.) UU_ l r, .`� �.1CTA/.� m ; //''�� 44 j r "..®.,y w: 101 P�d+/(�'�y m Lyn) / Ipso Yl e i Signature N pU3 L4G I i PRINT NAME OF REGISTERED OWNER / N TARY OR AGENT �- , I C� Ii y .••?I by G{ L.m61IcLL e1 7t Z. oRA)i9 7, 1)C-r....�'/1Vc� �ii �F• 8.30-07•••••'SO' PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY dia Q C? County/Office No.OR , ' �/' 'Ed,F WASN\".. I Title Not AND: . Dealer No.OR 2f J�C7/6 r -,,,....""w DEALERSHIP POSITION/AGEN OTARY Notary Expiration Date I 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and'ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. D BUILDING PERMIT OFFICE CERTIFICATION 0 the manufactured home has been affixed to the real property as described. I Certify that: building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# :' c, ) tc 1 .-vri ,x , y 6J17(,-, .. ( , ., SIGN6TURE/POSITION D TE TD 420-729MANUFHOMEAPPf_(R)2/02)I R(W)Page 1 of 2 2cnTURN ADDRES vsal • (-t -33q L��STATr OF WASHINGTON MANUFACTURED HOMEPLEAS CH' CK ONE l"=QY Yt �j ITLE ELIMINATION icEnsinG APPLICATION ['TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ['REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine, imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER 'YeiApi \l � LEN TH/WIDT(FEAT) VEHICLE IDENTIFICATION NUMBER(VIN) XX © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ❑ AFFIXED ❑ REMOVED fel �PEIVOrix PApDE a A Mai�` LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE .J111 ►`l�� U/ RT /•UAEt 6•1! ),.) © GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAt. of' 4k, ':`.. COUNTY N MBER NUMBER OF REGISTE D OWNERS NUMBER OF 0WNEl1r, ' NAME OF REGISTERED OWNER 1,, D• OML�RI CCOUVT�y`1A MB lt E00. v n \US L Y 1 J __tic) 'go (L A E OF A TI DNAL REGIS OWN R DOL CUSTOIAAMIALMI NUMBER oc: ---_ „,. DVS 'vo(` fL) ' V� 1 I``'��IS.-. STATE cZI,_CC)pE 9 NAME GAL OWNER 1 HUY� DOL USTOMER ACCOUNT NUMBER '7 . ' !.c_ C i.� ,*4'7 ( _G 1Y1, (Y) (1 .r L - l �� Ic - - NAME OF ADDITIONAL LEGAII OWNER 1,' DOL CUSTOMER ACCOUNT NUMBER ADD 4` --'�i CITY 111 TATE ZIP CODE 1 1 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION I certify that: IELthe manufactured home has been affixed to the real property as described. ❑ a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# er,t\ety\ Zmo\-e-C , SG° -"51 - 'g"cSO 131oo6 -( 3 SIGNATURE/POSITION DATE TD-420-729 MANUF HOME PL(R/2/02)OR(W)Page 1 of 2 BUILDING PERMIT APPLICATION ` - Jefferson County Building Department• County Courthouse • Port Townsend, Wash.98368 • 385-1310 N E I. LOCATION: geographic name S W SIDE OF ROAD FEET NE S W FROM INTERSECTI OF lJ ROAD AND , ROAD other specific location or landmark:, /,1JF/c— --�--E�� �1.�/��t.-� �- LEGAL DESCRIPTION: 11J CS - JO �4- ? (2 7- 9 AJ tf ( Lot Block ' Subdivision Tax Number 'h Section Section Township Range II. TYPE AND COST OF BUILDING - TYPE OF IMPROVEMENT BUILDING TYPE MOBILITY Jew building ngle Family E New County Resident ❑Addition /ti❑Multi-Family Is this structure to serve the residential number of units. ❑Alteration or commercial needs of those employed ❑Repair,replacement ❑Hotel,Motel, Dormitory at either the U.S. Navy's Trident or number of units Indian Island Facilities? ❑Wrecking Mobile Home • D Moving (relocation) ❑Other—Specify ❑YES ❑NO ❑ Foundation only USE OWNERSHIP _ Full-time Residence onprofit vate (individual institution,corporationetc.) , ❑Second Home: Recreation Cabin,etc. , ❑Public (Federal,State or local gov't.) UBC OCCUPANCY GROUP: ❑Second Home: Future conversion to permanent residence COST (Omit cents) Nonresidential— Describe in detail proposed use of buildings,e.g.,food • Cost of improvement $ processing plant, machine shop,laundry building at hospital,elementary To be installed but not included school,secondary school,college,parochial school,parking garage for in the above cost department store,rental office building,office building at industrial plant. a. Electrical If use of existing building is being changed, enter proposed use. b. Plumbing `� 7,t �JO% A, i/ c. Heating,air conditioning �jC� d. Other (elevator,etc.) • TOTAL COST OF IMPROVEMENT $ jt 4 a(.btl J III.SELECTED CHARACTERISTICS OF BUILDING - PRINCIPAL TYPE OF FRAME TYPE OF SEWAGE DISPOSAL DIMENSIONS J ElMasonry (wall bearing) ❑Public or Private •Number of Stories •Total square feet of floor area, ):.-)Nood Frame Individual (septic tank,etc.) all floors,based on exterior .❑Structural steel dimensions ! 1/ x 6 J ❑Reinforced concrete TYPE OF WATER SUPPLY •Total land area,sq.ft. L- •ice ❑Public or private company - l I, ❑Other—Specify , NUMBER OF OFF-STREET I1dTndividual (well,cistern) PARKING SPACES /��• Enclosed PRINCIPAL TYPE OF HEATING FUEL TYPE OF FIREPLACE E Gas Outdoors ❑Oil RESIDENTIAL BUILDINGS ONLY electricity Number of bedrooms TYPE OF MECHANICAL CI Coal I' Number of Full ❑Other—Specify bathrooms Partial -37i1 IV. IDENTIFICATION - 7 Name Mailing A dress— Number,street,city and State ZIP code Tel.No. Owner e• 0 r ( C/�L 1 7 / \v I ! / 2. `c- C \- Contractor State License No. 1 3. Architect The owner of this building and the undersigned agree to conform to all applicable laws. nature of applicant Address 6pplication date COL&QL A-\),-,-".534, ..)\-laka_Q _ 9:— gc - 74) PLANNING AREA "54' EFRE DISTRICT SCHOOL DISTRICT E ) WATER DISTRICT APPROVED BY OLYMPIC HEALTH DISTRICT: �; e_,._,,, , ` r)/4.,/,',. APP VED BY: ') PERMIT FEE ISSUE DATE PERMIT NUMBER .C&-- e''' '(--; il 0 C i 5-6 I BUILDING OFFICIAL , �� q...a `� The Printery —Port Townsend