HomeMy WebLinkAboutBLD2008-00153 ML
Sj ILDING PERMIT APPLICA•N Review
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD08-00153 Received Date: 4/16/2008
SITE ADDRESS: 90 COURSEY LN
PORT LUDLOW, 98365
OWNER: NANCY M HAYDEN PHONE: 360-437-9592
MICHAEL T HAYDEN
90 COURSEY LN
PORT LUDLOW WA 983658709 TAX 41
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 821083007 Section: 8 Township: 28 N Range: 01 E
CONTRACTOR: AK C RUCT PHONE: 360-379-9636
PO BOX 14
PORT HAD C 98339
C ractor's License ONC*922D1 Expires 3/21/2010
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION DEMO 621 SQ FT OF EXISTING SFR
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM MAIN:
VALUATION ADD'L: HEAT TYPE: EEE
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: 2 Exist: 2
Prop: 0 Prop: 0
Total: 2 Total: 2
Routing Date: �1 I ICQ
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $52.00 AMS 04/16/08 97145 /\ppRcVElJ
State Building Code $4.50 AMS 04/16/08 97145
Total: $56.50 JUL I 2008
Jefferson County Planning
&Building Department
PPP—
Jefferson County Building •ision Permit Niter:
Applicant:
BUILDING PERMIT INSPECTION APPROVALS \pplicable Code: International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
FINAL INSPECTION lb-2 - 14 (0'2— ic3-1
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
RECEIVED
• •
Olympic Region Clean Air Agency •.
2940-B Limited Lane NW CONDITIONALLY A'PR t VED ,,,,,,,,�
�� =l"�( WA 98502,,,�- Olympia, NOT APPROVED
., ORCA . / (360) 586-1044 or 1-800-422-5623 FOR COMPLIANCE WITH
ww..x r „t,,sw,* Fax: (360) 491-6308 www.ORCAA_•filiCAA REGULATION I
BY 0
Notification of Demolition Permit
it Is unlawful for any person to cause or allow the demolition(or major renovation)of any structure unless all asbestos-
containing materials have been removed from the area to be demolished. Work shall not commence on an asbestos project
or demolition unless the owner or operator has obtained written approval from ORCAA. A written application for a
demolition shall include a certification that there Is no known asbestos-containing material remaining in the area of the
structure.Project Site Address: 40 Cairsey 1 and _County: J-e-Paror,
City: Po r-i- L i,ci I Ucii, 1A)Q5h State: I—i , Zip: q r3 3(09
Starting Date: OS Jic J( K Completion Date: OS f 31IClg
* Mere is a 10 working day advance notification period from receipt of permit application)
Property Owner: fl7 i ha s l 4 h/Q nr y f-laydet elephone: 3600- L'3-1- si c c 7 Fax:
Mailing Address: 90 Coursey f r-,nQ_
City: Pbr± I u d l a Lk) State: (.0&. Zip: 9S Flo 5
Demolition Contractor.AK C o n s.\-(L)c.,c%o n State License#:AKC,0/v C-' 9, ,R .T
Mailing Address: P C C'c) HI I q
City: Pc c\- L0610,7) State: L A Zip: 9,.3 37
Contact Person: CI,A lc AI I0 n Telephone: 3(00 3 7 c I(c,3 0 Fax:
YES NO
V zDernalition by Wrecking or Dismantling?($25.00 fee)check if nonrefundable l------
V Training Fire Demolition? (If yes,attach fire department request for training tire)
I/' Renovation,Alteration,Remodeling,Maintenance,or other Construction?
Asbestos found or suspected*
"An ORCAA "Notice of Intent to Remove or Encapsulate Asbestos"form and appropriate fee must be submitted prier to any asbestos
removal work- Asbestos removal prajecla involving demolition must be preformed by a Certified Asbestos Contractor and all friable or
potentially friable asbestos must be removed before any demolition begins. Re'er to ORCAA Regulation 1 Article 14 for additional
requirements tlwl may apply.
Asbestos Survey Completed by
AHERA Certified Inspector . _I3 64 i 4 n p
Certification tY /6, /9074 % .XCipeS /o- /F-a�'
This approved permit mast Enclose S2s j/ Certification of the Asbestos Survey must L�'�~
be available at the job site rr�ocesaiug Fee accompany this form
1':ICOMMONIFormslasbeslos\DcmmPemtit.tioc
Rev.10/22/02
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DATE 1-1--c3`a
.4ON 7 Tt
4 06. JEFFERSON COUNTY 1 /
ti ' 'rI DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368 APR 1 6 2UU8
360/379-4450 • 360/379-4451 Fax
/,j p3 www.co.jefferson.wa.us/commdevelopment
S` NO RS Urn DCO
Master Permit Application MLA: b0 " 10
Projectt Description (include separate sheets as necessary):
I_..fit"✓r i c. .i%, 1 :. 1 C t"s1 r.,t, )<� ft.ose-
Tax Parcel Property
Number: Bi:2 1 Q�•3 cDd7 Size: .,,6-3 QC. "CS (acres/square feet)
Site Address and/or Directions to Property:
CIO C®v Ys ey Lane
Property Owner(s)of Record: 1.Ictncy -i rn icilciel 1 en
Telephone: 3(nc - t431- C3592, Fax: email:
Mailing Address: (40 Course y LQkiL,i Por+ I ()d iat) t' c4.. R 8 36 S
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What�, kind of Permit?(Check each box that applies
)w' uilding ❑Variance(Minor, Major or Reasonable Economic Use)
;Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
❑ Single Family 0 Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* ❑ BoJndary Line Adjustment
❑ Change of Use ❑Short Plat**
❑ Address ❑ Road Approach ❑ Binding Site Plan**
❑ Home Business 0 Cottagelndustry ❑ Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign ❑ 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 0 Tree Vegetation 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 its 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 ap i tion that he or she w nts prior notice. e�
Signature: (/d p� _2
Date: �'/ /(.p " o0
The action or actions Applic nt 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 code The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility f adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
� t Signature: 17( ai/d[jh Date: Ai• /(o -OS
G:\PemutCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
0
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:
11 if C c n 'i'ruc- tvi'3 (3tao) 379.9636, ( )
MAILING ADDRESS: P o. Box P419 f.... HQdlock,w4 EMAIL:
CONTRACTOR'S LICENSE gS33gWAINS 7
NUMBER: p K +,D/C 4k q 22Dl NUMBER r
ARCHITECT/ENGINEER: Puck �,st9rr (iJorks PHONE Igo )3BS- 38 FAX:( )
MAILING ADDRESS: a 3 �ild.rick5 St pfi--tbt send WG EMAIL -MU r ock6cabltspeed, con-)
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New $ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
Repair 0 Masonry SEP Permit#
% Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ig Private well ❑ Two Party
Type of Heat: Proposed: ❑ 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:
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 �.,o�c�,ee,U� ' ply _vg u,r,,, (ip,'unt. evisip ; ,,4„, ',
Main Floor Heated C . ' EH Bld App Review: `
-- Z.o, I L f-, - <. t- � 2 t
2nd Floor Heated ;• , , Consistency Review: 1
< o cirix�1 i e It o H 0Cla I,
Other Heated ' 1 Base fee: �_
Mezzanine • ,;` Additional Section:
Heated Basement : Plan Check fee:
Unheated Basement .j t ;, State Surcharge fee:
Other Unheated = Pot Water Review fee:
Garage/Carport " „ . SUBTOTAL
• 9 z.�
Decks r: 4 r 911/Rd Approach fee:
Other TOTAL: $ 51 5j
Receipt Number: CI 7 (-iC
Cash/Check Number: l�
1 n23
ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish
5 Soo c90 Initials: �-�-.: . -74..
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
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