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HomeMy WebLinkAboutBLD2007-00383 tILDING PERMIT APPLICATN MLLA07N004404 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00383 Received Date: 7/17/2007 SITE ADDRESS: 270 HARRINGTON DR QUILCENE, 98376 OWNER: TOM N EASTGARD PHONE: (206) 780-5067 REBECCA L EASTGARD 3967 EL uO LN NE BAIN:"IDG LAND WA 98110-4049 SUBDIVISION: Block: Lot: TX 17 PARCEL NUMBER: 601443013 Section: 34 Township: 26 N Range: 01 W CONTRACTOR: TO B DETERMINED PHONE: REPRESENTATIVE: ROG ' KATZ &ASSOCIATE ARCHITEC PHONE: (206) 842-8351 571 E'ICKSEN AVE NE (206) 780-5201 BAINB''IDGE ISLAND WA 98110 PROJECT DESCRIPTION DE 0 MFH AND DECK t TYPE OF WORK MOB SQUARE FOOTAGE: j{ TYPE OF IMP DEM VALUATION MAIN: CODE EDITION: 2006 ADD'L: HE f TYPE: OCCUPANCY: HEAT BASE: HE T TYPE: OCCUPANCY: NHEATED: # F STORIES: CONST TYPE: •THER: AHORELINE: CONST TYPE: GA:AGE: SETBACK: DEC' : BANK HEIGHT: SEWAGE DISPOSAL: ALT ___--- WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 2 Exist: 1 Prop: 0 Prop: 0 Total: 2 Total: 1 Routing Date: III I 6-1Cia,\ Type Amount Paid By: Date: Receipt: Approved/Date Permit $51.00 KAS 07/17/07 91518 State Building Code $4.50 KAS 07/17/07 91518 Total: $55.50 riiiik6_,.,,, gUN cJEFFERSOF UNTY • , DEPARTMENT OF COMMUNITY DEVELOPMENT ~ t `4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �qsp'� www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: (e)t/— / .$" Pr ' ct Description(include separate sheets as�necessary): f a '7tC t.—lam-/ 1/57-/N C, A *�-Aiu t Ac7z.tt2 a01y'L-c 4/ ..:. Tax Parcel /� 3 d �3 Property Number: Size: 2 •/1 ci 22-t' W i /j L (acres/square feet) Site Address and/or Directions to Property:, r` 2-7(i fi elA '7Z/v biZ. G,cc&f& 14/4- ` 0371' Property Owner(s)of Record: q")KY) C4S`1� C) Telephone: ?.-"4" 7 i-50k Fax: email: Mailing Address: -Niq Ir.L C/rrlb LAAJCAJE i -miete-;1)E iS, ra/,t c1 61/0 Applicant/Agent(if different from owner): J?c(a- I444-Ti1 A556C A-,' i 7 c75 (12p6en-,/e..,f,rz,} Telephone: ZG'Ip -I FZ"b. i Fax: Zvlo -7 tiO 5i-0 i email: PM/a El-€ ',-DG e4TZ•Ca1-•i Mailing Address: 5'7! ra r4(-56 AGUE ,/E ,e3Af-Aioie-;0C,E /S Q47 / //0 What kind of Permit?(Check each box that applies ❑Building ❑Variance(Minor,Major or Reasonable Economic Use) gi. Demolition Permit 0 Conditional Use[C(a), C(d),or C]** ❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home ❑ Modular ❑ Special Use(Essential Public Facilities)** ❑ Commercial* Line Adjustment ❑ Change of UseREIliffj-vrK;tc)itnitda **❑ Address ❑ Road Approach Binding Site Plan** ❑ Home Business ❑ Cottagelndustry ❑ Long Plat** ❑ Propane I 1 7 `l ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Sign ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management � t1,"p,(�llll,I t+�`Shoreline Management Substantial Development** ❑Site Plan Approval Advance Determin ) 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 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 rewired later i spections.,.Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application th ` r s is prior notice. '7 Signature:__ ($ � A� ) Date: 7 / / ,1 The action or ctions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangers species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endan red 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 corn iance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-tr n� sfera le res o ' i'ty for adhering to d wm lying w' the ESA. The Appli nt has read this disclaimer and signs and dates it below. Signature:` k � Date: 7`_,/ — .627 G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.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 0 Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: (: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: i Height, ❑ Individual System ❑ Repair ❑ Masonry 6," SEP Permit# l"') -- /6E) X' Demolition A. Other: Bedrooms: --�77 Water Supply: Alt*P�it t:-„kinr Existing: .2— Setback: x Private well ❑ Two Party Type of Heat: Proposed: (; / ❑ Public Total: l__ 3C 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: 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. Square Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH E3Id App Review: ,i BtD l7arrev.k. 2nd Floor Heated Consistency Review: ©VD-,2cm%:\'' Other Heated Base fee: 5 1 ` Mezzanine Additional Section: Heated Basement Plan Check fee: Unheated Basement i i'a���a" Ell') State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL 5 5,5v Decks (H �r ga 1 f f 1 A ' . 911/Rd Approach fee: Other TOTAL: $ ..rN 5 J C It .s Receipt Number: C\\5\55 Cash/Check Number: 1 \1—ltc ESTIMATED COST(REQUIRED) Date: 1 1� 1 b, •Fair market value of all labor and materials foundation to finish Initials: �,� G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc