HomeMy WebLinkAboutBLD2008-00192 litILDING PERMIT APPLICATION MLA08-00225
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD08-00192 Received Date: 5/8/2008
SITE ADDRESS: 71 CHINOOK DR
BRINNON, 98320
OWNER: KENNETH D MC CAIN JR PHONE: 360-577-6420
PATRICIA L MC CAIN
122 SHADYWOOD LN
KELSO WA 98626 SEAMOUNT ESTATES DIV 2
SUBDIVISION: Block: Lot: 17
PARCEL NUMBER: 993200017 Section: 29 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: BO PHONE. r
-�t'e-
17 � E DRIVE Lc' 'r-
INNO ' 8320 I n.1
PROJECT DESCRIPTIOP M/H (1973) PACIFICA, SERIAL #S0148
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN: 720
ADD'L: HEAT TYPE: , EEE
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUBLIC
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 Prop: 1
Total: 2 Total: 1
Routing Date: C
Y t_C5i
lc'
1
Type Amount Paid Bv: Date: Receipt: Approved/Date
Permit $168.00 AMS 05/08/08 97370
Potable Water Application $59.00 AMS 05/08/08 97370
Total: $227.00
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111LCK WESTERMANS Jefferson linty courthouse
ASSESSOR PO Rom 1220. Port Townsend,SI'.% 98368
13601 385-9105
MOBILE HOME :INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: ia-tYY p ` CCC 1 h
ADDRESS: I-7/ Shadywetrd Jn 4-J5'a GJa ?'mod .
PHONE NO_1YO-5-77- J.67
The par pose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous ownership and location of a mobile
home. This will help our office determine whether the mobile home is already on the
tax rolls in Jefferson County or if it has been moved to this county from another area.
1)MOBILE HOME DATA:
(A) MAKE !\ (H) MODEL ?ALA C A (C)YF,ttR l 1
(D► LENGTH GC) (E)WIDTH t 2- (F)SERIAL# S OILk
(G►YOUR PURCHASE PRICE(Do not include sales tax) PURCHASE DATE
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 30
(A) FROM WHOM DID YOU PURCHASE MOBILE i3oh
ADDRESS 3t-2-0 1 5-�-- I��.�r'l7 1�-� 1 �11�T of E Z oO9-Ov(7
(II) WAS MOBILE HOME ASSESSED IN JEFFERSONnnq COUNTY LAST YEAH Yes No
p 6c EL '� 00�g7 c C. 25
If Yes, Previous address of mobile. v c.14'4-t ' 'f ' ! r AT 6S Doi / 1...6T 2 S
If No, What County was Mobile assessed in last year.
3►WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes
(B)IF LOCATED IN MOBILE HOME PARK:
NAME &ADDRESS OF PARK Lot/Space#
(C) IF NOT LOCATED IN MOBIL ., :ROME PARK
NAME OF LAND OWNER: ci "Y/ C / a •�. m G C a 'h
LOCATION ADDRESS 7/ c-y i4 O Sr . 0 n h 41 �i 3 6
REAL PROPLRTY PARCEL#/DESCRIPTION 94 3 Z d do 17
MAY - 8 2008
446-'r
Signature of applicant
THANK YOU FOR YOUR HELP! / P g `i: G l A L . M C 4'd
SS-Q �LQ
JOI COSSELL, Property Technician
,GON
i)r c0 JEFFERSON COUNTY IIIa? ' '�q DEPARTMENT OF COMMUNITY DEVELOPMENT
'� 'N v ki 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�' p'� www.co.jefferson.wa.uslcommdevelopment
MAY - 8 200 .�
Master Permit Application MLA: OF-a r�l 7
Project Description(inclu a parate sheets as necessary): _
�' 7/ eJ 4' i -�,' �'� ,�:�� -o
Tax Parcel Property
Number: 9 ,3 6Q6 /(7 Size: (acres/square feet)
Site Address and/or Directions to Property: "se r}v41 c) tsj ' L— ` r-4 r 6 S — ri+ 2-"i c '. F A'!. lV-.ra r
r? 5isr� N lr,u A/ 17(2 Wiz - a r�✓at- ribr1_.A14 V, T-. d.6r 5
Property Owner(s)of ecord:�� �c ./)?GC-f%-xi
Telephone;3124-.5-7-: &O Fax: // 2 �A' email:
Mailing Address: /off 07 a)� /k%- t� 512Z 2G
Applicant/Agent(if different from owner): ta c-p e- -14 F i r� ��` t`c
TelephonefO- Fax: email:
Mailing Address: 17RTP2 --1PrZ ___ p k}` �,
What kind of Permit?(Check each box that applies
Building 0 Variance(Minor,Major or Reasonable Economic Use)
Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
0 Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
Rf Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
❑ Change of Use ❑Short Plat**
❑ Address 0 Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry 0 Long Plat**
❑ Propane ❑ 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
❑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:
c(1.6. Jj-
' DESI NATION OF AGENT
I hereby designate • to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE �1_, !/i G
v�� �1 �C-Zt.„,s,, _ Date:01- - 15 - d
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 at liabilities,judgments,court costs,reasonable attomey's fees and
expenses which may in any way accrue against Jefferson County as a result cf 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 appljcp
• tion that he or she wants prior notice.
Signature: ..e? GC� ,� U C'`G c'y`1 —. Date: "`.$d
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 lake"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 t.o 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-transfer le responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ./�..�..�i 1.
c('$st-r-ci — Date: , —/c O7X-7
• •
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 oft General Contractor for the proposed project. /1/�
Signature: �./rh+`a7/1(1�,/ �?,�-%r'��1� Date: 'IAr��/
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: ONE: 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:
CI New 0 Wood Existing: 0 Sewer
CI Addition 0 Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: Height: ❑ Individual System
CI Repair 0 Masonry SEP Permit#
CI Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: 0 Private well 0 Two Party
Type of Heat: Proposed: 0 Public
Total: Name of System:
If this is a Commercial Proiect 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:
1 Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 Other
Is this appliance being installed in a Manufactured I 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 Revisjion 3,::,.
Main Floor Heated EH BId App Review: i (0 co
2�Floor Heated Consistency Review: 131 to
Other Heated Base fee: J,_____
Mezzanine Additional Section:
Heated Basement Plan Check fee: _____
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee: on co
Garage/Carport SUBTOTAL AC! ) C)
pis 911/Rd Approach fee:
FY_ L51 c
Other TOTAL: $,/sCi�
Receipt Number: q-137c
Cash/Check Number:
h
ESTIMATED COST(REQUIRED) Date: _
•Fair market value of all labor and materials foundation to finish r
2--C;_____ .
Initials: _ __--
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc --
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