HomeMy WebLinkAboutBLD2010-00408V
MANUFA'TURED/MOBILE HOME INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD10-00408 Received Date: 12/16/2010
SITE ADDRESS: 23 ROBBINS RD Issue Date: 12/16/2010
NORDLAND, 98358
APPLICANT: RICHARD LLOYD TRUSTEE
LLOYD FAMILY TRUST
PO BOX 1630
PORT HADLOCK WA 983391630
SUBDIVISION: Block: Lot:
PARCEL#: 921084019 Section: 8 Township: 29 N Range: 01 E
CONTRACTOR/
DEALER
PROJECT DESCRIPTION: THIS IS NOT A PERMITmll1J""" TITLE ELIMINATION INSPECTION
oNLytitimilimmi
MAKE: YEAR: SIZE:
Directions
To Site:
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
TiA Q im:h,�,kc1�
IN
Lict
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
*01----4MN
JEFFERSOPOUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368 ( . /)1 < 7
360/379-4450 • 360/379-4451 Fax
q www.co.jefferson.wa.us/commdevelopment
HIND
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
V • y �, v-lv ,
Tax Parcel Number: • Property Size: (acres/square feet)
Site Address and/or Directions to Property:
Property Owner(s)of Record:
Telephone: Fax: email:
Mailing Address:
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
❑Building ❑Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
❑ Single Family ❑ Garage Attached/Detached ❑Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home . 0 Modular ❑ Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)**
❑ Change of Use 0 Boundary Line Adjustment
0 Address 0 Road Approach ❑Short Plat**
0 Home Business ❑Cottage Industry ❑ Binding Site Plan**
❑ Propane ❑ Long Plat**
❑ Sign ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑ Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑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 ❑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 own r/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 falsekod 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 Jeffersef 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• assumed unless the applicant informs the County in writing at the
time of the application that he or she wants prior notice. ..
Signature: Date:
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,shebrIt holds individual
and non-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date:
G:\PeniitCenter\###FORMS###\DRD FORMS\Current DAD Forms\Master Permit Application 5-29-08.doc
• •
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: Date:
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 Li Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
II 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 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:
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:
2`d Floor Heated Consistency Review:
Other Heated Base fee: )/i C.
Mezzanine Additional Section: /
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
"-2/ UG
-Decks 911/Rd Approach fee:
r Other TOTAL: $ /• G (s
Receipt Number: /-=2 75 1 C)
Cash/Check Number: Z 2 /
ESTIMATED COST(REQUIRED) Date: / -. _/�/ _/
•Fair market value of all labor and materials foundation to finish
Initials: ' ^ C/
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
• • lii/V--5 L2- , -.)?.00,
. BUILDING PERMIT APPLICATION
Jefferson County Building Department• County Courthouse • Port Townsend, Wash.98368 • 385-1310
Ir N E
I. LOCATION: geographic name S W SIDE OF ROAD FEET
NE
S W FROM INTERSECTION OF ROAD
p AND� _ f ROAD
other specific location or landmark: f -,Pali" / .
LEGAL DESCRIPTION: �/Lot Block Subdivis'o
. 3 BOA) r, t),_,ro ,
Tax Number 'h Section Section Township Range
II.TYPE AND COST OF BUILDING
TYPE OF IMPROVEMENT BUILDING TYPE MOBILITY
El New building El Single Family ❑New County Resident
%Addition ❑Multi-Family Is this structure to serve the residential
number of units or commercial needs of those employed
❑Alteration
❑Hotel,Motel, Dormitory at either the U.S.Navy's Trident or
❑Repair,replacement number of units Indian Island Facilities?
Wrecking ,4obile Home
Moving (relocation) ❑Other-Specify ❑YES jNO
❑Foundation only
___ - - USE
OWNERSHIP -- - - Full-time Residence
"Private (individual,corporation, ❑Second Home: Recreation Cabin,etc.
nonprofit institution,etc.) -
❑Public (Federal,State or local gov't.) UBC OCCUPAN(;Y GROUP: ❑Second Home: Future conversion to
permanent residence
COST (Omit cents) I Nonresidential- C cribe in data' roposed use of uildings,e.g.,food
• Cost of improvement $ 1300 -- proses 'Qg plant,mac.' e shop,laun building at ho 'tal,elementary
To be installed but not included school,s ondary schoo, oliege,parocht school,parkin arage for
in the abate cost department tore,rental of a building,office building at ina trial plant.
a. Electrical If u;e of exist' building is being changed,enter proposed use.
b., Plurr`>ing �, 4t lI--0 1 ( I 1 1 e . `- _. .- to ---
c. Heat`ng,air conditioning -'►14:Ci- G� f4//0 / y-'
d. Other (elo.ator,etc ) _ -
• TOTAL_COSrT OF IMPROVEMENT $ 3 3(O -• —
III.SELECTED CHARACTERISTICS OF BUILDING -
PRINCIPAL TYPE OF FRAME TYPE OF SEWAGE DISPOSAL DIMENSIONS
•Number of Stories
I]Masonry.(wall bearing) ri Public or Private
•Total square feet of floor area,
,., Wocd Frame ' Individual Is1ptic tank,etc.) all floors,based on exterior. ` Y /�
dimensions / / l
0 Structural steel • . ' - ----`
TYPE OF WATER SUPPLY •Total land area,sq.ft
O,Reir,forceri concrete �r'u't 1{
_ - -- - � ,ic or pr,:'�tu con"'ny -- - 1 El Specify..- •Other-Specit ---� NUMBER_ NUMBER OF OFF-STREET
0 Individual ('NCH cistern) PARKING SPACES
---- -- - Enclosed
PRINCIPAL TYPE OF HEA?ING FUEL TYPE OF FIFiEPL 1^:(;iOutdoors
--- 1
Gzs i
[1 oil RESIDENTIAL BUILDINGS ONLY I
El Electricity • • --- -- - - --- Number of bedrooms -
TYPE Cyr MEC:W.0/11'7 L • I
El.Coal Full. . . .. .
Number of 1
__-_-- 1
ElO':h -Ier Specify__---- bathrooms Partial
IV. IDENTIFICATION- _ _ _
Name - Mailing Address-• Number,street,city and State ZIP code Tel.No.
-.-
1 --- - � ___� �-��{g Qit) -Ct-s-cK J . _ 3 /3 2 a
Owner r.Lh. hv' -fa—,,,C..i wet—A f 8`,3s-e --- -
2 1--_ - -S a}c l.fcrnse No --: / (� •
:ontract • - Icli-�"re- 97. ,.1 Le g36S
3. , ___47/fr__ . •., ., , . ,, , .- _
Architect I - --- - -- — -
-1-.!!':. :'t.oer','f 1:i- s buildir•,g and'the undersigned aer.'e tc.xetfs rrr to all applicatul,laws.
aura of appl ca.
I,E'Ss f.pplicat:ondate __
it
PLANNING.AREA_—. __ _.._FIRE DISTPIC'C..—.-____—_. -•.r.-b�e0"... STFiICT _ __ WA,TE-R` TRICT—_—•_—__
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I I F.FF!i0` •=.D BY: I'E.RMl f t'-.; T ISSUc DATE - PERMIT NUMBER - - 1
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