HomeMy WebLinkAboutBLD2010-00097 • •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD10-00097 Received Date 4/1/2010
SITE ADDRESS: 1621 CAMP DISCOVERY RD Issue Date 7/13/2010
QUILCENE, 98376
APPLICANT: TODD R DAUGHERTY PHONE: 425-836-0873
KAAREN L DAUGHERTY
22102 NE 10TH PL
SAMMAMISH WA 98074-6863 TX 7
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 701224007 Section: 22 Township: 27N Range: 01W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, TODD R DAUGHERTY PHONE: 425-836-0873
if different: KAAREN L DAUGHERTY
22102 NE 10TH PL
SAMMAMISH WA 98074-6863
PROJECT DESCRIPTION: DEMO EXISTING CABIN
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 7/13/2011.
REQUIRED INSPECTION:
FinalApproval: S.-lb '' d
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
I:\F_BLD_Permit_Propane.rpt 10/29/19
EOLDING PERMIT APPLICATIa B RD10 00 Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD10-00097 Received Date: 4/1/2010
SITE ADDRESS: 1621 CAMP DISCOVERY RD
QUILCENE, 98376
OWNER: TODD R DAUGHERTY PHONE: 425-836-0873
KAAREN L DAUGHERTY
22102 NE 10TH PL
SAMMAMISH WA 98074-6863
SUBDIVISION: Block: Lot: TX 7
PARCEL NUMBER: 701224007 Section: 22 Township: 27 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI' DEMO EXISTING CABIN
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:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
'4— I" (C _)
Type Amount Paid Bv: Date: Receipt: Approved/Date
Permit $71.00 LYK 04/01/10 117501 APPROVED
State Building Code $4.50 LYK 04/01/10 117501
Total: $75.50 JUN i3
Jefferson County Planning
& Building Department
.TUL . - 1,010 TOTE L: 33 FP1 c'F:C FAx 110. 36U4;'IN f18 F. OF_I CO
2010-07-01 1423 DAUGHERTY•536087 >> 36049163013 0 P 2/2
141-rm\rri 04--1 4: A Ly
, ':i..ON r"�- itC ✓+'�Olympic Region Clean Air Agency 04-j)/ &ern'), ‘/,
,. am 294043 Limited Larne NW
/+'f Olympia,WA 98502 i Fh7C • 54 ' �y- '
.,. (360)586-1044•FAX(360)491-6308 esident1 ,l
�"^� ' = Port Angeles office(360)417-146G
4 ORCAA ,/ Raymond Office(360)942.2137 Demolition Permit
``'. ammo '"-"� www.ORCAA.org
This permit valid only for residential homeowner
residing in the dwelling after renovations
- Permit fee; $35.00 per structure. Non-refundable.
PROPERTY OWNER t
Name: Phone: (431)F514, Cal Ematil:'�dauelle.r�..@>iv mod,pr-/
C?bt l AD tAit ccr
f FAX: ( ) Mobile:kt?. k4e S?7_
Mailing Address: City: Statc: Zi
1. 21lpt KJE- lO� #�t� oc.Sa..e-^..r ,,,,
, . '
Site Address: L' h, - WA ��by
City. State: Zip:
l A6'Z► CAl •'I' 'Is,A S Qvtr Ra/ Qu l t—c laic w+4 ct r,a�s}
DEMOLITION CONTRACTOR Check if same as ptoperty owner information
Business Name: _Phone: NA She- OHC‘b Email:
5r1 Lb rX ,sti/Ar1nl FAX:
Onsite Contact: Phone: ' ' Mobile: ( )
't7^'m J D id,..;G'w_, FAX ( )
Mailing Address:
t9: State: Zip:
-U 0 k I-7 G art--r )-1A c .oc r ksiv4 l ;3`l
DEMOLITION INFORMATION -_-
#of Structures being demolish-are: Completion Date:
_f — -"17/I`--4 i Asbestos present Yes [ No_ Su ey ana ed YesN/7/IL /lb
Ha id t. ed bestow bee
emavcd Yes No
Avi:r , i2C;i t.,v4 -yil. i5 7as ,6.4a1._ ,,,swz.c.1-•Ir,<--F --/M
DEMOLITION PROJECT CATEGORY
[X]Complete Demolition
[ ]Training Fite Fire Agency:
[ )Renovation,Alteration,Remodeling,Maintenance,or other Construction I
I Nape read and will abide by the conditions tar forth in tbir parntlt and any addenda"' thereto. I do hereby certi3O that
all identified asbestos has been removed and the information in this application and supplemental data described harein
is, to the best of my knowledge, accurate and complete.
_� '6Au6+45ln
Y ____ _AZU:)
Applicant Name Signature Date
Date.A.itti.cp Z5ceived Payment Info_ Approved Asbestos Permit
COVE ]Cash • [ Disapproved Permit# to ASB00 '
)Check. # J Demolition Permit
JUL Credit Cart t Review date: 4/ /��/a 0 Permit#LDEMoc
�orc
Receive date_/I /I•C& Reviewed by:
.y
�4 a :, _, racy Lyra Only senc�(Isr Only rnry[Iso Only
09/19/08- -, ,s OVER
Srlik(314c , JEFFERSON CITY •
• •TA DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
4. po. www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: la!, riM '
Project Description(include separate sheets as necessary):
.-io Ek(S T- SFr ..
Tax Parcel Number: -70 1 - -2_2_44 , 0 0`-7 Property Size: I •]g IQe2t,S (acres/square feet)
Site Address and/or Directions to Property:
1 b Zl CAN\ .b r s CO v€may �C . CQ'IL-CEP€ 9 ' )3n b
Property Owner(s)of Record: ►b'L�� \--- 01,1)ait'6' t J /3-iv"i� �D. ..(r
Telephone: Li-Lc- �5._-4, hg•7. Fax: / email:- che.r-111.10, )Ws .br'4
Mailing Address: 2�-\OM (V CI b�`" ?L SAMMA•,,n.I sh 7 W 7 J J A ci,,n p
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
lding 0 Critical Areas Stewardship Plan
Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Single Family ❑ 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**
0 Propane 0 Long Plat**
0 :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
❑ 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 SIGNATUR s .--- 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 acy,ess an ight of entry will be assumed unless the applicant informs the County in writing at the
time of the a ts prior n icg.
/Signature: 2 Date: LI ) I U
The action or actions Applicant will undertake as a suit of the issuance of this p rmit 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-tr9j1sferab a res�ty for adher'n to and mplying with jgeESA. The Applicant has read this disclai era d signs and dates it below.
Signature: -------_ lilii-• -er:- . Date: —1 ) ) o
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc !!l
BUILDER STATEMENT •
The signer of this statement does hereb rtify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be as
•� ponsibilit the eneral Contractoyjor the proposed project
r Signature i r ate: \-1 i/) 0
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:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: _ Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
Total: Name of System:
If this is a Commercial Protect 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:
i Heat Stove i Cook Stove i Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 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: 0-I
2"°Floor Heated Consistency Review: .,r
Other Heated Base fee: ( '-
Mezzanine Additional Section: ____---
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: I— ��
Other Unheated Pot Water Review fee: ram- -
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $ I ��
Receipt Number: 1 I 1 r`i,I
Cash/Check Number: I„, �.
ESTIMATED COST(REQUIRED) Date: ��-�
*Fair market value of all labor and materials foundation to finish ,. r--
Initials: ---
f
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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