HomeMy WebLinkAboutBLD2011-00120 • •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00120 Received Date 5/12/2011
SITE ADDRESS: 1812 LINDSAY HILL RD Issue Date 5/17/2011
QUILCENE, 98376
APPLICANT: MATTHEW A SUITER PHONE:
1812 LINDSAY HILL RD
QUILCENE WA 98376-9521
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 701292005 Section: 29 Township: 27N Range: 01W
CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215
1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License KOZELHS027C3 Expires 1/6/2013
OWNER, MATTHEW A SUITER PHONE:
if different: 1812 LINDSAY HILL RD
QUILCENE WA 98376-9521
PROJECT DESCRIPTION: DEMO M/H
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 5/17/2012.
REQUIRED INSPECTION:
FinalApproval: (o-l3 -1 (
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
BLD11-00120
ILDING PERMIT APPLICAIIN Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00120 Received Date: 5/12/2011
SITE ADDRESS: 1812 LINDSAY HILL RD
QUILCENE, 98376
OWNER: MATTHEW A SUITER PHONE:
1812 LINDSAY HILL RD
QUILCENE WA 98376-9521
SUBDIVISION: Block: Lot: +
PARCEL NUMBER: 701292005 Section: 29 Township: 27 N Range: 01 W
CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215
1112 S JACOB MILLER RD
PORT TOWNSEND WA 98368
Contractor's License KOZELHS027C3 Expires 1/6/2013
REPRESENTATIVE: JAIME KOZELISKY PHONE: (360) 385-3215
1112 S JACOB MILLER RD (360) 385-3215
PORT TOWNSEND WA 98368
PROJECT DESCRIPTION DEMO M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP DEM
VALUATION MAIN:
CODE EDITION: 2009 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: CON
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amo P: aid Bv: Date: Receipt: Approved/Date
Permit $71.00 LYK 05/12/11 123497
State Building Code $4.50 LYK 05/12/11 123497 APPROVE['
Total: $75.50 II �/ L
MAY 11 2U11
Jefferson County Plannint
& Building Departmeni
• 0
,i7-- N cob JEFFERSON COUNTY
` DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street• Port Townsend•Washington 98368
4. 360/379-4450 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
•
Master Permit Application MLA: NC" Hu) (f(--6, '
Project Description(include separate sheets as necessary):
_ Mb fY�t1
Tax Parcel Number. ,'0 1 ? 2. L C Property Size: S A-t.(I (acres/square feet)
Site Address and/or Directions to Pro
I `. Lt a ,_. tt.0 u.d.Cei
"-Property Owners of Record:: . • /o tM4 r - Str, ►Te �-
Telephone: -7 of-(0y 1 Fax: / / email: • .
Mailing Address: (X((.� Ll 16Si f--�t.l ( .,�—�(ki aro 1. 0 .
•.ApplicantlAgent(if different from owner):,2r t 0,11 f- /G.; CAS(c�
•
Telephone: C 1-(' "120 2 - Fax: email: .
Mailing Address: . •
•
t kind of Permit?(Check each box that applies as 0 Lot or Road Segregation •
uilding 0 Cri Areas or,Mardshi
Demolition Permit ❑Vriance(Minor, aj r (�f
Single Family 0 Garage .Attached l Detached ❑Conditional Use[C(a),C( ,
O Manufactured Home. - .❑ Modular • - - q Discretionary'D'or Unn Use Classification
❑ Commercial* " • 0 Special Use(Essential Public Facilities)'"' 2 2011
O Change of Use ❑Boundary Line Adjustment;
❑ Address 0 Road Approach D Short Plat 1'
❑ Home Business 0 Cottage Industry 0 Binding Site Plan** i J
❑ Propane ❑Long Plat'* ! 1EFfERSON COUNTY
0 Sign • -- • ' - • ❑Planned Rural Residential[der/,glppn ;(PARR /19Ulift is"
❑Allowed"Yes'Use Consistency Analysis 0 Plat Vacation/Alteration" • - •-
O Stormwater Management 0 Shoreline Master Program.Exemption/Permit Revisions'*
❑Site Plan Approval Advance Determination($PAAD)• 0 Shoreline Management"Substantial Development•'
0 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 ❑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:
!! ,,Dg� IGNATION OF AGENT
I hereby designate I t'tj V L.L"'1---L ` to act as my agent in matters relating.to this application for pemiit(s).
7OwNER SIrNA1URE .-: i 1 Date: Li
By signing this application form,the ownedagent 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 attorneys 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 ary c' 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. Staff's access and right of entry will be 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 KpOtentiAl"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-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates'it below.
/Signature: Date:
• •
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 contradors.and that
they wilt 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:
CONTRACTORS LICENSE WAINS
7
NUMBER: / )0 , ^(S L-C is h n,i Q c" l/u1 e 1UMBER
ARCHITECT/ENGINEER: 1 PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL •
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
0 New 0 Wood Existing: ❑ Sewer
O Addition 0 Steel Proposed: Bank O Community System
❑ Alteration/Remodel 0 Concrete Total: Height: ❑ Individual System
❑ Repair 0 Masonry SEP Permit# (Y>1/
❑ Demolition 0 Other. . Bedrooms: Water Supply:
Existing: Setback: ❑ Private well Cl Two Party
Type of Heat: Proposed: 0 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.(ncludes owners,tenants,employees,etc) Current Proposed . . -
IBC Occupancy , IBC Type of construction: WM 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 Yank 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 I 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.
.. .. - . 1 > t � f SiQ;"` S. SSt.Sai � > iZ.-iY •%'..,1' ) i! , ✓`
S.uare Foota•e Current Pro•osed +. t _�1., �� . zC fhb�'� 1.r Y 1.l'_ ''Y -' ' c �6 Z �'
Main Floor Heated ,, :EH Bid App Review: rj5 . -
=Yt.•
2n2 Floor Heated Consistency Review: - •
Other Heated - ' , -:0' ,r
N , Base fee: #E• c
k '`= 4 i Additional Section: i MeY7ariine '';g—i_ 4-c Ad
Heated Basement `k u -Q.fi .4 Plan Check fee: M's 2. ��} .
f,;,
Unheated Basement .. Q � State- Surcharge fee; � � � -. .•
` ,V, s JE ERSON COUNTY.
Other Unheated. •, i"Pz„ .a Pot Water Review fee: .L OEPT.OF C ' ' t '' '
r x
Garage/Carport r l SUBTOTAL - - - - - .
Decks - ,f Yeti�:.911/Rd' - -
Approach fee:�;„ ,. - -
TOTAL
R
• Other S `
- Receipt N•umber: i 93c j97 •: • • • _
r ; � i CashlClieck Number, :.�. r
ESTIMATED COST(REQUIRED) Date: . Z J^ . }-
•Fair market value of al labor and materials foundation to R►ish s t W .
Initials: •• - • - . . •• .
MAY/12/2011/THU 11 : 59 AM ORCAA FAX No, 3604915308 F', 001/001
04/29/2011 0$'17 FAX 0 , 0 ICuvl
t3 ti, jFii
,,:iiE� Olympic Region Clan Air Agency 15t t td 0'
,4 ;� 2940-$Canted Ltne AtWt
O��pia.WA 98502 ...,,t .� .--1- l
ql (360)539-7610•FAX(360)491-6308 `.- �1
\% --" Post Angeles office(360)417 1466 Uemolition i ermit
,0,4 Q R CA3 .1tny*mond Office(360)942-2137
`' _ -AV anew ORCGAA.org
T.. . - - -
KCommercial Structure— nitfem` -40 w y wait period
Owner occupied residential dwelling— •. .Oily • r Notice
_PROPERTY OWNER s osbn IArn e.6,64 4
.
.,,. - �/i _ ..3 Phon3�p'•. 'i7�(c'• Rm4il• L,c I't L
`PAM (. Mobile:(
it, a-5 N ,&osr • A-46-- W.g-T----P.4) -0 IVA- 3.b g
Site Ad ess: State Zi
i i z L; say i.1.4'II I_ i i Ce-YV2- v1A 9 i3 7,4
DEMOLITION CONTRACTOR f _I Check if tome as pro, emawner itsfonnztton _
Business Nam Phone: (30) 3SS - A F,sz+aa
oZCfi5k S 4kDtme Y+JicaS 1nC FAR; (36�) 3$3--321 ko71nce1 i eh
Oasite Contact' -FAX:
) �e,rti� Moba3e , b' ?•fZp2
JLL.i'he roZeitsF y FAX: ( )
Mang/Wrest
3 rr� e ? p r+Ti 5�►4-r� S r�� Y 3 .
DEMOLITION INFORMATION— —
of Structures being demolished: Start a , = Date= 1i (
(u173 it le ha rn,— -art 1 b
.pre sent _Yes . No Saworv,stteache _ __,No Han all ident4Red ashes tbs been
removed jes„___,Z'Jo
DEMOLITION PRO "CT CATEGOKY
Complete Demolition '� — —
t )Training e—Fire Ag ,
j 1 Renovation,AltetadQn,Remodeling Maintenance or other Constcoctioa
1. I Emeigtncy—Additional Fee of$50.O1/(muss be accompanied by Gavennoeat Oedema Declarauaa- merdal ,
I haver ad aid will abide by the animations set fattb.io thisperauitaasd any sddendetm thereto. I do 1zezekp cattle
that al identified asbestos.has been removed and the Infoucsdatt 1st this application nod seeppletnetrtal data
desmihed herein is,to the best ofn2y knowfraisF,scent2te.and.compkte.
Applicant Name- ••- -- Signature- Date •
t - - 1
'�_ _- -Dah3.�ppSs �'-' . pa1��arinn. ".�` .-�`,.:...`: +;, , = I �Cash approval Pennit it �
- • _ - t O' credi Cat -- R iewdsie f/Z_LL Peamit# 7N 0619
, * -y> - Reviewed km n
_ -ur b k, .9,QenL7 Use Only Ageno'Use 947 -OM-Lie Ong
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