HomeMy WebLinkAboutBLD2009-00097 UILDING PERMIT APPLICAON MRLA09-00p105
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00097 Received Date: 3/31/2009
SITE ADDRESS: 758 N JACOB MILLER RD
PORT TOWNSEND, 98368
OWNER: KATHLEEN HUDSON PHONE: (360) 385-3385
4567 MCNEILL ST
PORT TOWNSEND WA 98368-2105
TIBBALS LAKE PARK
SUBDIVISION: Block: 63 Lot: 1-10
PARCEL NUMBER: 999006301 Section: 32 Township: 31 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: TOM BURKE PHONE: (360) 381-5062
300 W ARCADIA
PORT TOWNSEND WA 98368
PROJECT DESCRIPTION NEW SATTILLITE BEDROOM SUITE W/BATHROOM
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 407
VALUATION 30,244.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2006 HEAT BASE: HEAT TYPE: SOL
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: CITY
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 1 Prop: 1
Total: 1 Total: 1
Routing Date: 4 1 ` O
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $451.85 KAS 03/31/09 105626
Plan Check $293.70 KAS 03/31/09 105626
State Building Code $4.50 KAS 03/31/09 105626
Total: $750.05
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*elk"' 0OL. JEFFERSON COUNTY
A DEPARTMENT OF COMMUNITY DEVELOPMENT
`' ` nn��`4 621 Sheridan Street• Port Townsend •Washington 98368 1_� _31 2009
. . 360/379-4450 • 360/379-4451 Fax
`rfiIlJ p www.co.jefferson.wa.us/commdevelopment
JEFFERSON COUNTY O
Master Permit Application MLA: Qq-1
Project Description(include separate sheets as necessary):
•:501-e,\ ; ke, .bebVoo,1" S_u; {
Tax Parcel Number: ggq00 ,301 4. q'lq 00( 203 Property Size: 3, /'- ac✓e S (acres/square feet)
Site Address and/or Directions to Property: (( III f; q t- c7-5 K' 0(Jr�✓{Sb &M 'k e, /
ti W i atcoLi k bIP
; v I'} ��' ki tivvu i`1US�H' SA-,rQtriq%tT -700 ' , p✓open t/ ova ✓;u,�, �
Property Owner(s)of Record: u
Telephone: 3 (v D - 3 g5 - 3£CS Fax: email: ka to 3 I7S1 LCaIo(e.spee -Lou.,
Mailing Address: 4 5 t 7 A e;11 S} P 9 u 3/o F{
Applicant/Agent(if different from owner): i),,„, ---')u,(i e.
Telephone: 3 6 0.3' I - 51)6,2_ Fax: email: -104.t k 044)_e I i k// ,C c w,
Mailing Address: )DO ,. T 2?3 (e s
What kind of Permit?(Check each box that applies ❑Lot or Road Segregation
,building 0 Critical Areas Stewardship Plan
❑ Demolition Permit 0 Variance(Minor,Major or Reasonable Economic Use)
Z1 Single Family . °R 0 Garage Attached/Detached 0 Conditional Use[C(a), C(d),or CJ**
❑ Manufactured Home .0 Modular • - - 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)'`*
❑ Change of Use ❑Boundary Line Adjustment
❑ Address 0 Road Approach 0 Short Plat**
❑ Home Business 0 Cottage Industry 0 Binding Site Plan**
❑ Propane 0 Long Plat**
0 Sign - • ❑Planned Rural Residential Development(PRRD)/Amendments** .
❑Allowed"Yes"Use Consistency Analysis ❑Plat Vacation/Alteration**
❑ Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference 0 Tree Vegetation Request
**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 inn .3 u r k e to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE % (] L - `�/ (l,Gu _ Date: �3 31 101
By signing this applicatio 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 require later inspecti s. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the a pli ti ' at he or'she ant /prior notice.
Signature: J Date: ``2)/31 / n cj
The action or ions 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 violat the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you r in complian wit the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfe 'r sponsi ility f r ad ring to and complying with the ESA. The Applicant has read this disclaimer and igns and dates it below.
/
Signature: -C._ Date: �'j),,3 I 6 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 assumin th r ponsibility the enerai Contractor for the proposed project.
Signature: /.h-c_ Date: k3/3 i/6
GENERAL CONTRA TOR 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:
Ir' New fiK Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: I Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: I Height: ` j Individual System
❑ Repair ❑ Masonry SEP Permit# SE.eud-o o 1 i 4
O Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well 0 Two Party
Type of Heat: Proposed: 1 ,e' Public
5 t iD S> Total: l Name of System: Cc.'4-i
_ So\UI✓ & elf Jii
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:
1 Underground Tank 1 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/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.
f �W 1Y ^> �73bV2g 13�•x� ��� ? °�K �'- _g , - n
n� el � � V r % f
Square Footage Current Pro oSect � �10 i o- e cr Pf' i � 4M *r 4.1 „y «33M±t:- 2 0, ,j•
Main Floor Heated ,r 0.7 4 . Bld Apo Review:
2"0 Floor Heated :r Consistency Review:
Other Heated _ " Base fee: �^-+}51, Q C
* ,t i }.., t Kt r, 1 UJ
Mezzanine C ; ' r ' ,Additional Section:
Heated BasementilrO '; Plan Check fee:
— n� aq3,
Unheated Basement Mil ,, State Surcharge fee:
w 4 . 5a
Other Unheated Pot Water Review fee: _________.
Garage/Carport 3 SUBTOTAL ri c A ^r
—Decks _ _ 911/Rd Approach fee:
Other _ TOTAL: $ ,50,(�
}
,, Receipt Number: 105(Dato
- -, ' Cash/Check Number:
ESTIMATED COST(REQUIRED) DateZ)19)11.
�, I
.Fair market value of all labor and materials foundation to finish ) _
Initials:
30)000 _
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