HomeMy WebLinkAboutBLD2011-00291 BUILDING PERMIT APPLICAO N ReAew Type23
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00291 Received Date: 10/20/2011
SITE ADDRESS: 83 GRAND FIR ST
CHIMACUM, 98325
OWNER: CHRISTOPHE ADAMS PHONE: 360-385-5189
94 ALDER DR
PORT TOWNSEND WA 983689460
EL CAMANO DIVIDE SHORT PLAT
SUBDIVISION: Block: Lot: 1
PARCEL NUMBER: 901101028 Section: 10 Township: 29 N Range: 01 W
CONTRACTOR: LND SERVICES PHONE: 253-536-6948
15010 74TH AVE E
PUYALLUP WA 98373
Contractor's License LNDSEI"173DA Expires 8/1/2013
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP M/H ADU
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP ADU
VALUATION MAIN: 1,188
CODE EDITION: 2009 ADD'L: HEAT TYPE: EEE
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL: ALT
WATER SYSTEM: 2PARTYWELL
BEDROOMS: BATHROOMS:
Exist: 0 Exist: 0
Prop: 2 P
Total: 2 Total: 2
Routing Date:�--
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $213.00 LYK 10 0/11 128270
Potable Water Application $62.00 LYK 10 0/11 128270
Total: $275.00
•
9,, Sorz
oZ
c. A. ` Ga_ _ _
44.0
`'rya �-.� �4 `�
--.. ... G�I�e� 14ite et-1 4- .-bkn WYM. . , .L , .- /112i c_g_0. -.1.) C!`--t 3Lb
t ��.�rr tires► ,,, a-7 ar�..aL-// -- / g GO4f.1 Cc .2C> 20,,
171.421Cle 6" 644,
Pa/ C. 11,.. CA C
-- ,A-Le/L--
ac �� '
C V
! '^) JAN - 5 2012
rd
JEFFERSON COUNTY
DEPT.OF COMMUNITY DEVELOPMENT
JACK WVESTERMAN III • Jefferson Counourihonse
ASSESSOR PO Box 1220, fort Townsend, WA 98368
(360)385-9105
MOBILE HOME INFORMATION FORM
OWNER'S NAME/MAILING ADDRESS:
NAME: a 1-`
ADDRESS: 1 . _ia"Vef
�1A� TGjyi J L)/4 ci �Cj
PHONE NO.
The purpose of this questionnaire is to obtain information regarding either the
current location of a mobile home or the previous owner hip-and--location-of-a-mobile
home. This will help our office determine whether the m L' h4 c N raI i y lOii, the
tax rolls in Jefferson County or if it has been moved to th si nn1-from anoth . area.
1 MOBILE HOME 111 OCT 2 2011
DATA: U • J
�i ' i EFFERSON COUNTY
(A) MAKE -_04►k)('-,1 (B) MODEL .1) COMMON
(D) LENGTH 2111 (E) WIDTH a--) (F) SERIAL #P,R StigAgqt-ziIti-t:/'
(G) YOUR PURCHASE PRICE (Do not include sales tax) PURCHASE DATECCY/`iV
2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW
y� vMOVE TO QUESTION 3)
(A) FROM WHOM DID YOU PURCHASE MOBILE I S (VtL G+ -
gyp,,,� _
ADDRESS .- .) P' 4cp1 S' - kif ,,V! 1K6 N 9 79
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes
If Yes, Previous address of mobile.
If No, What County was Mobile assessed in last year. / TSip
3)WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes
(B)IF LOCATED IN MOBILE HOME PARK:
NAME & ADDRESS OF PARK Lot/Space #
(C) IF NOT LOCATED IN MOBILE HOME PARK:
NAME OF LAND OWNER: / ,, \
LOCATION ADDRESS X,X t 1-rG,d Rr , 4r .yr) L
I
A
REAL PROPERTY PARCEL #/DESCRIPTIO L( 7 �/1b i /)Q
`�idrr� j
Q
Signature d applicant
THANK YOU FOR YOUR HELP!
Lauralee Kiesel, Property Technician
• •
0
-,3
l i
r1 - , 1
% k , , -- --.
.,
11?-5:14
I
....---- 'll A- ----- 1
I
C -k- ---i--; c
I
't 1, \
CT
..---___________C„, "T-- 1 ___E-
./ i
A 1
-5-A _1
,),
:::
�Q, sJ <,O /��
e•soN 0
06, JEFFERSOISUNTY I
W4. • ' \� 14 DEPARTMENT OF COMMUNITY DEVELOPMENT
In �tINp ` '4 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
p� www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: 1 (--1 4
Project Description(include sep to heets a:nece'slsary):
_ A D u_____
No \ha -- 0 Li-00
Tax Parcel Number: 1w Property Size:r ,�('j�+ 't 1 j acres/square feet)
Site Address and/or Directions to Property:
C Ira:.--j c,jF ` g
Property Owner(s)of Record: `` �
Telephone: .� C_ Fax: email: 7(c�G^/Y,'S' fi.11r J Pta
Mailing Address: Q U-/ A ,...)/d r r t5/P y' � ol'� ()or! 5.c •
Applicant/Age t if differecntt from owner):
Telephone: '. O Fax: email:' 9dr,5 ,auc kV
Mailing Address: , Q' Or'J i c rat- ((j U.) cjK;�,�q V
What kind of Permit? (Check each box that applies ❑ Lot or Road Segregation
uilding 0 Critical Areas Stewardship Plan
Demolition Permit 0 Variance(Minor, M jer-or-Reaseraak��Frnnnmic t�P
❑ Single Family 0 Garage Attached/Detached 0 Conditional Use[C,a), ( pr
Manufactured Home .0 Modular - 0 Discretionary"D"ot,Unh a ariatiorh 11
-01 Commercial* 0 Special Use(Esse tial Public Facilities)**
❑ Change of Use 0 Boundary Line Adjstmer!t
❑ Address 0 Road Approach 0 Short Plat** ( '1 1' ' ('(',T 2
❑ Home Business 0 Cottage Industry 0 Binding Site Plan** 'I 11 1 J
❑ Propane ❑ Long Plat** , •
❑ Sign -- . 0 Planned hurai Re idential DevvtgpRggRt FO)/Amendm nts**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alter tion C't P;.OF CC'AMUN!TY DE!'Et PMENT
❑ Stormwater Management 0 Shoreline Master Program emp ion arts"'
❑ 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 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 a d void.
I further agree to save,indemnify an hol harrnless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way ac ue gainst Jefferson C untyas a result of or in consequence of the granting of this permit.
I further agree to provide access a d r-ht of entry to,deffer`on,county and its employees,representatives or agents for the sole purpose of application
review and any required laterins c ns. Sta s acces a d right of entry will be assumed unless the applicant informs the County i writing at the
time of the application that he o s _ants pr r notice.' 1 0/2/�J j /
Signature: ,' / �i �y', Date:
l /l
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 d a potential"take" an a angered species as those terms are defined in the federal law known as the
"Endangered Species Act"or" Jefferson Coun m e o assurances to the applicant that the actions that will be undertaken because this
permit has been issued will o • ate the ESA. A i i ual,group or ncy can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are i c liance •h the J Cou ent code.The Applicant acknowledges that he,she r it holds • dividual
and non-transferable res ib" d rin e ESA. The Applicant has read this disclaimers' man d e i elow.
Signature: Date: I
1i
•BUILDER STATEMENT
The signer of this state e ' oes hereb ce at they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming r ilit oft I Co a r for the proposed project. r�
Signature: Date: I V 24
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
2.5j 53f 69lig ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS /1
NUMBER: NUMBER C(,�„
D ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
j(' New 4 Wood Existing: 0 G Sewer
❑ Addition 0 Steel Proposed: Bank 0 Community System
O Alteration/Remodel 0 Concrete Total Height: A-Individual System 0
O Repair 0 MasonrySi-' SEP Permit#.'EPO/-II Z
Bedrooms: Water Supply:
O Demolition ❑ Other: pp y:
Existing: 0 Setback: X Private well Two Party)
Type of Heat: Proposed: a _r ❑ Public
Total: c4 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 1 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:
• 73
2`d Floor Heated Consistency Review:
Other Heated Base fee: 2 l
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee: /0- v
Garage/Carport SUBTOTAL 0 0
Decks 911/Rd Approach fee: 41 4 A.11p oQ _qE
Other TOTAL: $�q aQ '1
Receipt Number: `aa"'10
Cash/Check Number: (p�
ESTIMATED COST(REQUIRED) Date: L� "
'Fair market value of all labor and materials foundation to finish it* t t
Initials:
70
�ao#r'L' Er S
m -
n
--1
_______iir ,c4V-Zr --___ —kir
kto
tri
D + _ �.
73
0 lir 1 \
-3!) ..
0
0 -g • ib, . 0 i-k 'ei
' z
,S)
-CP ---. *
Ni
II
4
.. 1: 11_ an 5? 1 it I
% 1) ,
zi
m 1....
v
m i ) ,
k.R ,t-
cn
VI - -4--________. ; jo .
___1CO
t.
`
'i
LY\\..-- t,-;\ k
t_ ,.,
/ �-5/1 ` •
�
i , v4- , -6-.)
'leit(S") i
. k
I 10 re•-* '1.1 ,
It
7 -...,. • e o2. . ,_
__________ _14 \
_1
74
N ike .3
t....-
00 / +
r
O ,
i
I
4,..,_,, 4, 1;\
Ai---6'.T.._
g
m
D
o
0
m
cn
cn
Pe
13
I
o .
z
m
z
c
g
DI
73
-n c_
cm c 7 C T
can o N --
T00 S. 't 4:9-C9 4
10
5 • k
zt
PCI R) c • r:
0
........ 0 §
W:,-) , _',.- , fii