HomeMy WebLinkAboutBLD2009-00260 MLA09-00265
111BUILDING PERMIT APPLIC/OON Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00260 Received Date: 8/5/2009
SITE ADDRESS: 1265 GRIFFITH POINT RD
NORDLAND, 98358
OWNER: JAMES SURGENT PHONE: 360-396-9595
DEVON A SURGENT
1414 241ST ST SE
BOTHELL WA 98021-9742
SUBDIVISION: Block: Lot: TX561
PARCEL NUMBER: 021321032 Section: 32 Township: 30 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOF CARPORT
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION 20,000.00 ADD'L: HEAT TYPE: UH
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY.
OCCUPANCY: UNHEATED: #OF STORIES:
OTHER:
CONST TYPE: GARAGE: 485 SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 0 Prop: 0
Total: 0 .--Total: 0
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $321.25 LYK 08/05/09 110689
Plan Check $208.81 LYK 08/05/09 110689
State Building Code $4.50 LYK 08/05/09 110689
Total: $534.56
I i
(--":_sON�gO6 JEFFERSON COUNTY
' A DEPARTMENT OF COMMUNITY DEVELOPMENT
'' 621 Sheridan Street• Port Townsend •Washington 98368
�$ 360/379-4450. 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: (`q-p9C0 5
Pijject Description(i dude sep sheets as necessary):
y
CJ1 AU vax Parcel Number: Property Size: (acres/square feet)
Site Address and/or Directions to Property:
I �� t� r k.cc t�.f` ?6t,�-k 2 , 1.1 A cis‘7)s
Property Owner(s)of Record: �t Yh c' P r?�I w� <
Telephone: ;)0(t - '.t6 - (16 9`i Fax: 42 ` -(1-20 - i oe ce email: \—S 11 ale ILO rrrtcyl elm.Mailing Address: 17-.'2)2 C 11)4- C.1_ N e e A VC-vek `..)r\ c n
Applicant/Agent(if different from owner):
Telephone: Fax: — email:
Mailing Address:
Wh•t kind of Permit?(Check each box that applies 0 Lot or Road Segregation
•':uilding 0 Critical Areas Stewardship Plan
• Demolition Permit ri Variance(Minor,Major or Reasonable Economic Use)
❑ Single Family g Attached/ etached U Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .0 odular ==_ - 0 Discretionary"D"or Unnamed Use Classification
0 Commercial* 0 Special Use(Essential Public Facilities)*"
❑ Change of Use 0 Boundary Line Adjustment
0 Address 0 Road Approach 0 Short Plat**
❑Home Business 0 Cottage Industry 0 Binding Site Plan**
0 Propane ❑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)* 0 Shoreline Management Substantial Development'"`
❑Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment
0 Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference 0 Tree Vegetation Request
**Requires a Pre-Application Conference
Please i tify 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 attomey'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 an• an required later ins.-« ons. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the -.. cation that he .r - e wants prior notice.
Signature: =— .�. �' Date: S7 1/ ')
imminrr-
The action or :i.ions Applicant will un.'i ake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangerec[ .ecies and could lead t: . potential"take"of an endangered species as those terms are defined in the federal law known as the
'Endangered Species Acr 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 violet lie ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even ' are in compli with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-trans rab responsibili r adhering to and complying with the ESA. The Applicant has read this discla e > n and dates it below.
Signature: f� . m Date: O 6ci
Ill •
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 ass 'ng the res `ibility of the General Contractor for the proposed project.
Signature: " Date:
GENERAL CO RACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
�'0 )4) _ .-R ( ).S) `fAo 400
MAILING ADDRESS: I���a_i'��-t a m e �f,Amo,t gccas> EMAIL. c S uk f Cjp ia C YI/\S vl . C()WA
CONTRACTOR'S LICENSE ))) WAIN
NUMBER: NUMBER
ARCHITECT/ENGINEER' PHONE (. (,) 4-i _1�j i FAX:( )a�" ��'9
-K�al1n��7_ �-7e��1 ����Ave � 1
MAILING ADDRESSEMAII
: 7t. 5 Y\Cc 1a kd •j Ck 1.0
-
Project Type: Frame Type: Bath oms: t� Shoreline: Type of Sewage Disposal:
ANew X.,Wood Existing: O ❑ Sewer
❑ Addition CS-Steel Proposed: 0 Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: G Height: t fa Individual System
❑ Repair ❑ Masonry J o I - 10 SEP Permit#07- 2 5
❑ Other. Bedrooms: Water Supply:
❑ Demolition Existing: CD Setback:
❑ Private well ❑ Two Party
Proposed: 0 b i K.Public
Type n�,f it Total:
U N eof Sys em
If this is a Commercial Project you must answer the following_ 6-1 p 4 Q, 0J18 ptryt` [' '
Number of Parking Spaces: Current t) Proposed: 0 Number of ADA Parking Spaces:
Number of orrt rpants(includes owners,tenants,employees,etc) Current � Proposed O
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / o
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.
Current Proposed "i+ !. , 1 .fir." `" ,� ! !.
Square Footage � �:-::" -:'. . '''',,•T'',IW,4".1,,!..i-?:,: ��± .
Main Floor Heated - EH Bld App Review:
WI SFR-
2nd Floor Heated Consistency Review: LZ /`^ =9
Other Heated Base fee:
_ '321-2C.
—Mezzanine m ' J-ASE--4L-
Heated Basement Plan Check fee:
Unheated Basement + State Surcharge fee: 4`S—t°
Other Untie ....) Pot Water Review fee:
Garage/ arport s l SUBTOTAL
Decks '' 911/Rd Approach fee:
F
Other K, t : TOTAL: $53L,3-6
xF Receipt Number: 1 ( O)(C
Cash/Check Number: ci
1
52.
ESTIMATED COST(REQUIRED) Date: �
.Fair market v ue of all la frteteri ndation to finish tom==
0 10.6 0 Initials:
Page 1 of 1
11110
Lisa Yobbagy-Keller
From: jim surgent[j_surgent@msn.com]
Sent: Monday, August 31, 2009 3:06 PM
To: Lisa Yobbagy-Keller
Subject: Carport Cancellation
Hello Lisa,
This email is to confirm our conversation that we are canceling our permit for the carport. The
permit number for the carport is BLD09-260. Everything else is still a go.
Thank You,
Jim Surgent
Get back to school stuff for them and cashback for you. Try Bing now.
.01114
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AUG 3 1 2009
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8/31/2009
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