HomeMy WebLinkAboutBLD2007-00233 41RUILDING PERIIJIIT APPLICAtN MLA07-00251
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00233 Received Date: 5/15/2007
SITE ADDRESS: 1113QUILCENE AVE
QUILCENE, 98376
OWNER: RICK P EMMERSON PHONE: 360$56-5959
KATHLEEN E EMMERSON
3175 NORTH SHORE RD
BELLINGHAM WA 98226
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 702243017 Section: 24 Township: 27 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW CABIN 3 (OF 3) WITHIN FOOTPRINT OF FIRE DAMAGED
QUILCENE HOTEL (CABIN '911 - 11B QUILCENE AVE)
TYPE OF WORK 3-4 SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 394
VALUATION 34,000.00 ADD'L: 196 HEAT TYPE: EEE
CODE EDITION: 2003 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: 26 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: PUD
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 1 Prop: 1
Total: 1 Total: 1
Routing Date: 5 11 hot
0
Type Amount Paid Bv: Date: Receipt: Approved/Date
Total:
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��4�,�'gON COS JEFFERSO COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT _-
ti
1 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
qs, O� www.co.jefferson.wa.us/commdevelopment , n
ITNZ . s:;-,, I _.
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
8 / H/z/ A
cq 8/hfs r a' 'viow S i ri L
14 LD r SI T
Tax Parcel Property
Number: w 2 3 d / '7 Size: / 4 Lf-t-` (acres/square feet)
Site Address and/or Directions to Property:
It Qi/r / LGr fi 6 AV
Property Owner(s)of Record: .i /C,f! 4- k f TN ( t Fl 1 ill T &' /2 4 v it
Telephone: 3 6 d 6 3" 6 5 9 C9 Fax: email:
Mailing Address: 3 / 7S hd/LTlt 5 //ARJ /2p, ig G1,6/n 6 frf,4 41 I Wei, 96%,2 2.6
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies
POuilding 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
0 Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
' Commercial* ❑ Boundary Line Adjustment
❑ Change of Use 0 Short Plat**
❑ Address 0 Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry 0 Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Sign 0 Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management ❑ Shoreline Management Substantial Development**
❑Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
0 Temporary Use 0 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 0 Tree Vegetaion Request
*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. Staff's access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the applicatio hat he or she ants prior notice.
Signature: 4/
'?s'vtl ie„�-./7 -_".` _____,Sz.._
Date: ✓h
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact uponrone 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 code.The Applicant acknowledges that he,she or it holds individual
and non-transferable re onsibility for dhering to and complying with the ESA. The Applicant has read this disclaimer and signs an dates it below.
Signature: / ' i ,(...•�yi''_'`-_ Date: //1/4977c C 7
!:•\PP...,:r('r..r.,.\tl34ftPnwniC+4 \Intl r.-In A sc\r.•__._.n. . . .
•• • •
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 r sponsibility of the General Contractor for the proposed project.
f
Signature: Date: 4/°",A ` if. ri /
i
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:
,.b New ,O, Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: I Bank El Community System
❑ Alteration/Remodel ❑ Concrete Total: i Height: ❑ Individual System
❑ Repair ❑ Masonry Bedrooms: SEPePermit
Supply:r1.1.4.4,it# '9 S7-
❑ Demolition El Other:Other:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ( .la Public
Total: ( Name of System: P 4 L? F1
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: S Proposed: Number of ADA Parking Spaces: /
Number of occupants(includes owners,tenants,employees,etc) Current .2, Proposed •
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes /1P
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
i Underground Tank I Above ground Tank Size of Propane Tank:
I Heat Stove i Cook Stove I Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i 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. 411�
Square Footage Current Proposed For Office Use Only° • At ,o'unt • r , Revis o`n . .
Main Floor Heated 3 g,! EH Bld App Review:
Y .=J
2nd Floor Heated Consistency Review:
Other Heated i...O /96 Base fee: I3�
sa,
Mezzanine Additional Section:
Heated Basement Plan Check fee: 13 40
Unheated Basement State Surcharge fee: <1.50
—
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL Soo 5--
Decks 911/Rd Approach fee:
at tt?lam *, \5 _
Other fl/H t t / TOTAL: $g ' 0Jt
`� Receipt Number: 8 D,ll '......,
Cash/Check Number: ' r �.. �
ESTIMATED COST(REQUIRED) Date: L)(69 MAY 1 5 2007 i Lj
'Fair market value of all labor and materials foundation to finish 1
3 (I b Q C5 Initials: j
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