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Home My WebLink AboutBLD2011-00095 GILDING PERMIT APPLICAIIN BL v Reviewiew T Ty095 ype: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD11-00095 Received Date: 4/20/2011 SITE ADDRESS: 221 MONTGOMERY LN PORT LUDLOW, 98365 OWNER: JOHN W FRIEBERG PHONE: 360-437-9833 BARBARA J FRIEBERG 221 MONTGOMERY LN PORT LUDLOW WA 98365-9601 PORT LUDLOW NO. 2 SUBDIVISION: Block: Lot: 52 PARCEL NUMBER: 990600150 Section: 9 Township: 28 N Range: 01 E CONTRACTOR: CLOISE & MIKE CONSTRUCTION INC PHONE: 360-340-1176 PO BOX 2042 PORT ORCHARD WA 98366 Contractor's License CLOISMC991L7 Expires 8/31/2012 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION RE-ROOF - REPLACE SHAKE W/ COMPOSITION TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 12,500.00 ADD'L: HEAT TYPE CODE EDITION: 2009 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: Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $223.25 LYK 04/20/11 123425 Plan Check $145.11 LYK 04/20/11 123425 State Building Code $4.50 LYK 04/20/11 123425 Total: $372.86 Jefferson County Building Dig ion Permit Num. BLD11-00095 Applicant: FRIEBERG BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2009 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 Miscellaneous SHEATHING FINAL INSPECTION /`..0 (i 43, FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR ON 00 • �4, d JEFFERSON COUNTY 4, ' \ IA DEPARTMENT OF COMMUNITY DEVELOPMENT 'w 'N. "4 621 Sheridan Street• Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �p"� www.co.jefferson.wa.us/commdevelopment Ili Master Permit Application MLA: it) (n(1)- eG'_t\ Pjojest es;anption include separate sheets as necessary): - - (. , r� �� s/� rc� ��s1�l/ �� ar =°M�Oos, W1 4,1I l l/ ', 1 Al- Tax Parcel Number: 0 (x0(50, Property Size: ,3 (acres/square feet) Site Address and/or Directions to Property: _ Z/ it/0 'a° e'll 1-0/1 — Part bzi�i6'ev k4 Property Owner(s)of Record: i e I/ Telephone: U— 3- Fax: email: John-rf;e6(f��ir,6 ./-v/}r� Mailing Address: SG?j'►^.e_ ` Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: W at kind of Permit?(Check each box that applies 0 Lot or Road Segregation �f uilding 0 Critical Areas ifas Stewardship nob f� (] 2 ❑ Demolition Permit 0 Variance(Minor,Major or el ❑ Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a), CO C]** ❑ Manufactured Home .0 Modular - - 0 Discretionary"D"or Unne Use Classification ❑ Commercial* 0 Special Use(Essential Pu is ecilitjkj '* 2 0 2011 ❑ Change of Use 0 Boundary Line Adjustmen ❑ Address ❑ Road Approach El Short Plat** ❑ Home Business 0 Cottage Industry 0 Binding Site Plan** JEFFERSON COUNTY ❑ Propane 0 Long Plat** DEPT.OF.COMMl1NITY DEVELOPMENT ❑ Sign •. 0 Planned Rural Residenti2l Development(rrcrcui/AmenamenTs"" ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration*" El 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* El 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 ent to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. S,,'' s access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application t�t h or she w.�,,•riot tire. `Signature: A Date: N- // The action or a w io -Applicant will undertake as result of the issuance of this permit may negatively impact upon one or more threatened or endangered sp es 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 th fferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable r sp nsibili for a g t_o nd complying with the ESA. The Applicant has read this disclaims and signs and dates it below. /Signature: Date: l/_ (-- )-- /i G:\PemritCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc III IIII 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: ( /c Ic - a (3� "c) 7/Ci 'Gl/`-// ( O 7.Y--fig 3 7 MAILING ADDRESS: p 0, /fi C'-I x zZ- T d Q/`G,I/n) Yv f EMAIL: CONTRACTOR'S LICENSE qd 3 t/s WAINS NUMBER: ('/p/SPi(— cCil-7 NUMBER ARCHITECT/ENGINEER: l,,0,S/'. �PMGv,,� PHONE ( ) 5pf�/_ FAX:( ) MAILING ADDRESS: (AAA'��. 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 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 FoodService? Yes / No ' If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: 1 Underground Tank 1 Above ground Tank Size of Propane Tank: 1 Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 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. S uare Foota a Current Pro osed jr-Office U A -A at a evision, - Main Floor Heated EH BId App Review: 2"0 Floor Heated • Consistency Review: Other Heated Base fee: c 93 a3 Mezzanine Additional Section: Heated Basement Plan Check fee: C Unheated Basement State Surcharge fee: f Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: Other TOTAL: $ �2�� Receipt Number: i J ,. , it Cash/Check Number: ;(I 1(l ------------- ESTIMATED COST(REQUI5E ) Date: i(_ZU, -- *Fair market value of all laborand materials foundation to finish _—_-l --�- - — St /ZI Sie Initials: G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc -D m 0 c— m 0 z > 3 m , c---------- c•le . c-, > ...,, m • -... 4* Cd\ ......., , . IL------'------ -5 — , m ' > --2 _ • -- 0 ‘..., . .: f _..i M ' ? 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