HomeMy WebLinkAboutBLD2010-00028 IBU BLD10-00028ILDING PERMIT APPLICA N Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
RMIT #: BLD10-00028 Received Date: 1/27/2010
E ADDRESS: 300 DISNEY RD
NORDLAND, 98358
VNER: VALERIE 0 KOSCHNICK PHONE: 360-643-1317
LIFE ESTATE
300 DISNEY RD
NORDLAND WA 983589609
JBDIVISION: Block: Lot: TX 2
\RCEL NUMBER: 921094007 Section: 9 Township: 29 N Range: 01 E
ONTRACTOR: OWNER/BUILDER PHONE:
ZEPRESENTATIVE: PHONE:
PROJECT DESCRIPTION COUCOU FROM SFR TO HTD SHOP/STORAGE -REMOVE
BEDROOMS, PLUMBING & COOKING APPLIANCES
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP COU MAIN:
VALUATION ADD'L: HEAT TYPE: EEE
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE SHORELINE:
GARAGE: 1,148 SETBACK:
CONST TYPE: DECK: 128
BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: 3 Exist: 1
Prop: -3 Prop: -1
Total: 0
Routing Date:
(-2 7— 10
Type Amount Paid By: Date: Receipt: Approved/Date
Change of Use or $426.00 LYK 01/27/10 113711 PIDRJVE[)
State Building Code $4.50 LYK 01/27/10 113711
Total: $430.50 FEB l 101U
Jefferson County Planninc
&Building Department
• a
CONDITIONS for Building Permit# :BLD10-00028
1.) Contact Health Department after verification that plumbing fixtures have been removed
and inspection by building department. SEP09-19 will not be finaled without this
verification nor can a certificate of occupancy to the residence under BLD09-188 and 189.
Jefferson County Building Divn Permit Numb.
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
(471\
FINAL INSPECTION . 4.1;41(,
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
44�`�S�N cot, JEFFERSON OUNTY
ti ' 7j DEPARTMENT OF COMMUNITY DEVELOPMENT
'4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
4:4 www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: O (1Lq 2 Lb
Project Description(include separate sheets as necessary):
cAo,,, d o•c Use —SrP S `St Y c
A
•
Tax Parcel Number: 702/(�'q t90"7 Property Size: / e re* S (acres/square feet)
ite Address and/or Directions to Property: J �}300 l S#7 e y p /11� G� n I '1. 7 b3 ,
•roperty Owner(s)of Record: i�k1 et S 1(J C' .� c
lephone: 6 '3 -13i .7 Fax: email:
ailing Address: 300 L s n eT ,�J/ . ,t ,-6,1 J 9.1?j y)
)plicant/Agent(if different from owner):
ephone: Fax:
email:
iling Address:
at kind of Permit?(Check each box that applies ❑Lot or Road Segregation
;wilding 0 Critical Areas Stewardship Plan
1 Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
Single Family 0 Garage Attached/Detached ❑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 ❑Short Plat**
iome Business 0 Cottage Industry ❑ Binding Site Plan**
ropane 0 Long Plat**
yn 0 Planned Rural Residential Development(PRRD)/Amendments**
lowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration**
ormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
`.e Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
mporary Use 0 Shoreline Management Variance
reless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment
rest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
"May require a Pre—Application Conference ❑Tree Vegetation Request
**Requires a Pre-Application Conference
identify any other local,state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
designate to act as my agent in matters relating to this application for permit(s).
3IGNATURE
Date:
j this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
in this permit being null and void.
Tree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
Nhich may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
ree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
application pat he or sh9 wants prior notice.
I l� • L t-er : z_ l > l
Date:
it actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
species and Could lead to a potential"take"of an endangered species as those terms are defined in the tederal law known as the
i Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
een issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
n if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
sferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclai er and signs and dates it below.
Date: 1 2 7 //(-J
###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
• a
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: .,V t A • 7 "' �-✓ Date: 1 /L '. /
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: Type:T e: Bathrooms: Shoreline: Type of Sewage Disposal:❑ New ❑ Wood Existing: � ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: - Height: ❑ Individual System
❑ Mason SEP Permit#
Repair ry Bedrooms: Water Supply:
❑ Demolition ID Other: Existing: Setback: ❑ Private well ❑ Two Party
Tyge,of Heat: Proposed: —-3 ❑ Public
C..w C-k-f lc_ Total: Name of System:
If this is a Commercial Project you must answer the following: Number of ADA Parking Spaces:
Number of Parking Spaces: Current: Proposed: Proposed
Number of occupants(includes owners,tenants,employees,etc) Current p
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 For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review: r7 —
1
2nd Floor Heated Consistency Review:
Other Heated Base fee: 0 D u -Ilan
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: 53
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $ ,
Receipt Number: 1131 I I
Cash/Check Number: I ICI
ESTIMATED COST(REQUIRED) Date: e9 9
.Fair market value of all labor and materials foundation to finish Initials:
G:\PerritCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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