HomeMy WebLinkAboutBLD2009-00230 0 •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD09-00230 Received Date 7/20/2009
SITE ADDRESS: 3103 CLEARWATER RD Issue Date 8/20/2009
FORKS, 98331
APPLICANT: DAVID A EMMETT TRUSTEE PHONE: (360) 962-2130
JUDITH A EMMETT TRUSTEE
PO BOX 208
ROSEBURG OR 97470-0036 +
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 412183002 Section: 18 Township: 24N Range: 12W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, DAVID A EMMETT TRUSTEE PHONE: (360) 962-2130
if different: JUDITH A EMMETT TRUSTEE
PO BOX 208
ROSEBURG OR 97470-0036
PROJECT DESCRIPTION: DEMOLISH HOUSE - NO MLA IREQ'D
Directions
To Site:
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 8/20/2010.
REQUIRED INSPECTION:
FinalApproval: , it'"ZL—I°
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
SPECIAL CONDITIONS APPLY - SEE REVERSE
HOT LINE AVAILABLE 24 HOURS A DAY
WILDING PERMIT APPLICATION BL Review T Ty y230
pe:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00230 Received Date: 7/20/2009
SITE ADDRESS: 3105'8e-31 CLEARWATER RD
FORKS, 98331
OWNER: DAVID A EMMETT TRUSTEE PHONE: (360) 962-2130
JUDITH A EMMETT TRUSTEE
PO BOX 208
ROSEBURG OR 97470-0036
SUBDIVISION: Block: Lot: +
PARCEL NUMBER: 412183002 Section: 18 Township: 24 N Range: 12 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI` DEMOLISH HOUSE - NO MLA REQ'D
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2006 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK. BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS, BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
7/ o/tqII
Type Amount Paid By: Date: Receipt: AppvrADMIcin
Permit $71.00 KAS 07/20/09 108770
State Building Code $4.50 KAS 07/20/09 108770
Total: $75.50
AUG 9Dr
Jefferson County Piat ni
&Building Department
• •
SPECIAL CONDITIONS FOR CASE#BLD09-00230:
1.) Approval by the Health Department for this demolition permit is based on the owners
signed acknowledgement that they will be decommissioning the existing septic system
prior to final of this building permit. No records could be located for the system and no
evaluation has been completed. This approval for demolishing the residence does not
ensure future building approval. Any future onsite sewage system shall meet code in
effect at the time of application.
I:\F_BLD_Permit_Propane.rpt 10/29/19
`G 610\CLE,1,1. • •
` '1i1
P Olympic Region Clean Air Agency
° "- � 'yc,, 2940-B Limited Lane NW Owner Occupied
f7 Olympia, WA 98502
#rr (360) 586 1044 • FAX (360) 491-6308 Residential Asbestos
O RCA A °1 Port Angeles Office (360) 417-1466
`'tygg „�t�' Raymond Office (360) 942-2137 Removal Permit
�'�.Th'.[RSOM.u�Sb�O .
www.ORCAA.org
***This permit valid only for residential homeowner residing in the dwelling***
Permit fee: $30.00. Non-refundable.
APPLICANT
Name: 8/1vgq) 4 Ems err ,1vO %noir7J t E,u &T/riNs#Wykione: (J o ) cr ,z -o2130 Email:
- E Aim ITT St Ail ve Mtisr- J '`FAX: ( ) Mobile: ( )
Mailing Address: City: State: Zip:
,7,33.? C l elm ta 6- 06 4)4- r6.ur
Site Address: City: State: Zip:
3 id C1 e -?-8£ R0/10 c* 4.1/f- I ' 33/
PROJECT INFORMATION
Start Date: Completion Date:, Work Shift Days: Work Shift Hours:
it u&-tLc% /0i o2d9 .4_u6 sr- /91 .24.3' M_."1"-✓W ✓th /Sa/Su cif rc ry 9-17,rs
# of Structures: Total Quantity to be Square Feet: Linear Feet:
.1 Removed 7 ii-S—
Name and location of Disposal Site: Will this structure be demolished after asbestos
C't(G.J,{: \ ,oo( -(e,,, \ c' ,s_r Jet-rAkio,) removal X Yes _No
Will all identified asbestos be removed rom the
structure X Yes No
Check Material being removed:
Boiler/Furnace Duct Insulation Pipe Insulation Fireproofing Paints
_ Plaster Cement Board Cement Pipe Flooring Roofing
Textured Coating Other F-1.42N2 l i t-
I have read and will abide by the conditions set forth in this permit and any addendum thereto. I do hereby
certify that the information in this application and supplemental data described herein is, to the best of my
knowledge, accurate and complete.
V��(0 '! _ Ater;, ee 9,..„_-,i 7/I. /G
$ F
Tap(rp,
4_ C,f,t4-retr T-RW-e'' "retelet (7_, -/-797'ze
Applicant Name Signature Date
Date. prplie`atron eived Payment Info. Approved Asbestos Pe mit
[ ] Cash [ ] Disapproved Permit# d1 ASB00ZYS-
44
ilk 1 7 20n [✓heck: # ,31e Demolition Kermit
[ ] Credit Card Review date:07-/ 14-/0a Permit# iiii DEMOO•34
... Receive date: / '-7/ 1 Reviewed by: \ Survey:XYes [ ] No
gency Use Only Agency Use Only Agency Use 1y Agency Use Only
10/21/08 OVER
fen*,..
ON C' JEFFERSON UNTY •
' DEPARTMENT OF COMMUNITY DEVELOPMENT
` ''4 621 Sheridan Street• Port Townsend •Washington:98368
360/379-4450 • 360/379-445i Fax
# www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: nn tom- J?(( ID
Project Description(include separate sheets as necessa,
�L/,daltsj� c<,LS EHSON (JUUV? C►(,I)
Tax Parcel Number: 1�I 1 • T'G' = Property Size: ,k�'J5' - t rc - ' r'tL -'y`l-,(acres/square feet)
Site Address and/or Directions to Property: S it'' C L ell 61">I-1YR kJ, (- t"`k 5, ry 4
r j- ,- i-h.., 1 1 ',-r pip 147 Ca Y,! c'Ler,-►z. I✓4/eri Rd - 6.i. I- / 441Le5 It; /Aicy/ene -
Property Owners)of Record:U1/vn> R rK• tI �e?if5n'e5 i•M�'r'/'i HP//[Y j 'lr'Sl- .IT
Telephone: 31'0 — `/6,� 7 13c, Fax: email:
Mailing Address: > C'Cr l�i..Arfrt'!Z gel, 10ill/�S 1 104- 4( 's.�, f
Applicant/Agent(if different from owner): -42 t'i> LF/li n-r -r
Telephone: -'C'C' `/" X — 02 i 3 C} Fax: email:
Mailing Address: 333 . (:Ietif-Riev-r f'R A' . reAiA-5 4,r,� /`-,>;
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
®Building 0 Critical Areas Stewardship Plan
jQ Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
NI Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .0 Modular - 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)**
❑ Change of Use 0 Boundary Line Adjustment
❑ Address 0 Road Approach 0 Short Plat**
❑ Home Business 0 Cottage Industry 0 Binding Site Plan**
❑ Propane 0 Long Plat**
❑Sign - 0 Planned Rural Residential Development(PRRD)/Amendments** '
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration**
❑Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* ❑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 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 application_th e or shesrior notice. ,r
`' ``Signature:o77e-wp/f • z..a,�-i4g;" a v, ,,•L.. ( • L i c Date: 7/13�C J
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"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-tran rable respon ility for.aaddhh�rinito and complying with the ESA. The Applicant has read this disclaimer/ and signs and dates it below.
Signature: i ...r/6. 1.�C'G/ -7i ,ti',ee' ; -e,t! /�/, L{,'i� ' '� Date: 71 �3l C�.
( /•, «�Lc,. rr
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
07/21/2009 13:26 360379 JEFF CO PERMITq R PAGE 03/04
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 contradors'and that
they will be assumming the 7nsibi the GeneContrador for the proposed project. /Signature:�J/� "Nv Date' TJ'2 L1 r 7
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:
O New 0 Wood .. Existing: i i Sewer
O Addition 0 Steel Proposed: . ; Bank ❑ Community System
O Alteration/Remodel 0 Concrete Total: Height: 0 Individual System
O Repair 0 Masonry SEP Permit#'
O Demolition CI Other: . Sadroams: Water Supply:
Existing: Setback: 0 Private well 0 Two Party
Type of Heat: Proposed: C1 Public
Total: Name of System:- '
If this,is a Commercial Proiactyou must answer the following:
Number of Parking Spaces: Current: lP',rot�. Number of ADA Parking Spaces:
Number of occupants(includes owners,to '. �C koy 1 it Proposed •
IBC Occupancy: IBC Type Instruction: . Will you have Food',Sbrvice?.Yes I No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that applir: •
I Underground Tank I Above ground Tank jut 2 0 Aligii of Propane Tank:
I Heat Stove 1 Cook Stove I Woodstove 1 Fireplace Insert I Hot Water Tank I Pellet Stove 1 Other .
Is this appliance being Installed In a Manufactured./Mobile.H'jon ? Yes / No
When applying far a permit to install a profl�} 0 , 't1 O abliubmit 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 are.
v). r_. , t e •• r i t••, .Oi7 atl °`a Iti"t r ',•, i+ J,* ,n- f fc 1 {� )11:1y
u: 6 1 k,' a :. "1"'dtt bid n , i '4t' L.f4t' ,:.' rr tll `r , ,��t<< + f X•�,1 ;�I,} ��� � < .t 3 �a, ti1�1�� .Square Footage Current ,Pro••sea (, ,di.Lti .i..�./.5,*,,ri�� , 1 r:e 4. 14 1 i 1 ,...:i( ti�rl:U ' :',:.t'.a.l.f::'tl' 1t:....
Main Floor Heated `. �i"' .717a,_0()
i ,,. EH Bid App Review:
y „1d y"v''t 4` '
2"�Floor Heated •i ,K,,,r ' Consistency Review:
14 - �,;'� der
Other Heated 4 i�p" ''u 5, es Base fee: / L J. A)O
r ti, '4,04 1rlf' I (/
i<r�d YE'r`lt ?
4, , Add;uonal Se�iord:
•ik. r r'r
v : rs
Heated Basement '° , .,,k,,r Plan Check fee:
i'.. Ir r!?? nit Z,
Unheated Basement (,, I,4 f""4;,f c',` State Surcharge fee: 1 50
Other Unheated • 'W 'd4 Pot Water Review fee:
Garage/Carport F " ` r a; `
+ ,. SUBTOTAL
" t sr 'q ;, 14 8.50
Decks 11 Y d ', i,,,,St,,i 911/Rd Approach fee:
Other"� a ; '4''': TOTAL: $ lLI 8_ 50 _
k:: jt 4. ,A..pf.s w Receipt Number: 0 [] '7 0
4 u 1i► `r
IP: h Z+ Cash/Check Number: �� —
ESTIMATED COST(REQUIRED) Date: loci
.Fair marker value of all labor end metoials foundation'to finish r tl
Initials:
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