HomeMy WebLinkAboutBLD2012-00120 RILDING PERMIT APPLICATIN MLA12-00084
Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00120 Received Date: 4/17/2012
SITE ADDRESS: 30 KEM ST
PORT HADLOCK, 98339
OWNER: DAVID G BELL PHONE: 360-535-2066
MARILYN P BELL
30 KEM ST
PORT HADLOCK WA 98339-9534 CHALMER'S 2ND ADDITION
SUBDIVISION: Block: 8 Lot: 15
PARCEL NUMBER: 942900806 Section: 3 Township: 29 N Range: 01 W
CONTRACTOR: MOUNTAIN VIEW BUILDERS PHONE: 360-683-2484
PO BOX 754
SEQUIM WA 98282
Contractor's License MOUNTVB899RK Expires 12/12/2013
REPRESENTATIVE: MOUNTAIN VIEW BUILDERS PHONE: 360-461-0934
PHILLIP COLLINS
PO BOX 754
PROJECT DESCRIPTIOr NEW ADDITIONS TO EXIST SFR TO ENLARGE 2 BEDROOMS, ADD
BATH &ADD LAUNDRY ROOM
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP ADD MAIN: 366
VALUATION 46,000.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY: R-3 UNHEATED: # OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: 05783
BEDROOMS: BATHROOMS:
Exist: 2 Exist: 1
Prop: 0 Prop: 1
Total: 2 Total: 2 - -�
Routing Date:
'-1 — 7 -12
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $603.35 LYK 04/17/12 131645
Plan Check $392.18 LYK 04/17/12 131645
State Building Code $4.50 LYK 04/17/12 131645
Total: $1,000.03
1 •
rON & JEFFERSOPOUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
`• '4 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax
4' p� www.co.jefferson.wa.us/commdevelopment
'1`S$ING
Master Permit Application MLA: is ' 4
Project Description(include separate sheets as necessary):
l X"2-z,c ra d (2- A-S t-i- C,WSJ A KC) " X l4 LAU 1s.1 .P -/? ',60 i"✓
Tax Parcel Number: `l If -CA 0 0 So Property Size: g r- t Z, S .F . (acres/square feet)
Site Address and/or Directions to Property:
So Ki-N1 `31- i NAbLo
Property Owner(s)of Record: DAVI iJ 4r-y0 MQe.(L-4(.i t_t_-4.-•
Telephone: c>`1,J "' Fax: Nt-')- email: Nor
Mailing Address: ?A Iti1E.
Applicant/Agent(if different from owner): ?I2IiL1A P COL--i nt5 P1 - MT v t\A) 12, I t f1'5
Telephone: -60 '-l-6( O`-154 Fax: NA- email:
Mailing Address: P.D • P'°X 'j 4 S vi'tvl ! \li,A (-9}`6')e)-
What kind of Permit? (Check each box that applies 0 Lot or Road Segregation
2SBuilding 0 Critical Areas Stewardship Plan
LDemolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
Single Family O DN 11 OIL] Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .0 Modular - 0 Discretionary"D"or Urnameri l lc rlaccifir•atirmq
❑ Commercial* 0 Special Use( sse tirral� I It
-)7
V (�
❑ Change of Use 0 Boundary LinelA �tnent
❑ Address 0 Road Approach 0 Short Plat** I l L I
❑ Home Business 0 Cottage Industry 0 Binding Site Plan_,.. I
❑ Propane 0 Long Plat** I ,
l i APR 1 7 . 20i2
O .
❑ Sign 0 Planned Rural;Residential Development(PRRD dments**
❑Allowed"Yes" Use Consistency Analysis 0 Plat Vacation/Alterati n**
❑ Stormwater Management 0 Shoreline Master Program d4, it Revision **
0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Man, gemegtT$9lM9ntia{primi nt**
❑Temporary Use 0 Shoreline Management
❑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 Mr• N)l `N Thu t 12_`) to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE /,)4,_/22e!•- -mil [:6 Date: 4 cl .'.'(�
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 a ss and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required I er" pections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the application al h r she wants prior notice.
Signature: ( Date: 4 l )7----
The action or actions A pli nt 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 issuewill of 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 a`e) ompliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable e ibility for adhering to and complying with the ESA. The Applicant has read this disclaimerc and signs and dates it below.
Signature: `l Date: -I CI "jZ
• •
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:
•
NT• \J rEAAi t ;v 1 i 5 (2.„6s1 e- ,O 4- ( )
MAILING ADDRESS: c-I,b, (�c•):. .-7y4 EMAIL: 1.4 -
CONTRACTOR'S LICENSE WAINS
NUMBER: C Cl-M uN.'TV t`)599 1< — NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: - . EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
E New X Wood Existing: I C Sewer
C Addition ❑ Steel Proposed: ! • Bank ❑ Community System
X Alteration/Remodel C Concrete Total: '- _ Height: X Individual System
C Repair C Masonry — SEP Permit# api ,DS
rs-
Demolition C Other: Bedrooms: Water Supply:
Existing: > Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: 1.e' ❑ Public
e 1-...:C12 tv Total: Name of System:GG-krxp✓
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:
1 Underground Tank 1 Above ground Tank Size of Propane Tank:
1 Heat Stove i Cook Stove i Woodstove 1 Fireplace Insert i Hot Water Tank i 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.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated i + O EH Bld App Review: ��
22 Floor Heated I____ Consistency Review: ^D,_r
Other Heated Base fee: a
Mezzanine r_ Additional Section: ,
Heated Basement i Plan Check fee: 39.
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
IDA s ,o3
Decks 911/Rd Approach fee:
Other TOTAL: $ I a S . 03
Receipt Number: 13 1
Cash/Check Number: aa(a
_ __ --
ESTIMATED COST(REQUIRED) _ Date:
•Fei[market lue of all labor and aterial�foundaflon-tq finish 1—
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