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Home My WebLink AboutBLD2012-00130 tILDING PERMIT APPLICA1IN BLDI2-00130 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD12-00130 Received Date: 4/25/2012 SITE ADDRESS: 266 MOONDANCE LN PORT LUDLOW, 98365 OWNER: ROWELL D CAMPBELL PHONE: KAREN L CAMPBELL 266 MOONDANCE LN PORT LUDLOW WA 983659566 HUCKLEBERRY HILL SHORT PLAT SUBDIVISION: Block: Lot: 4 PARCEL NUMBER: 821334096 Section: 33 Township: 28 N Range: 01 E CONTRACTOR: HOME DEPOT AT-HOME-SVCS PHONE: 800-381-5699 140 COUNTY LINE RD#101 PACIFIC WA 98047 REPRESENTATIVE: NW PERMIT INC PHONE: (360) 945-2787 1345 GULF RD (360) 945-2091 POINT ROBERTS WA 98281 PROJECT DESCRIPTIOI RE-ROOF TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 15,495.00 ADD'L: HEAT TYPE CODE EDITION: 2009 HEAT BASE: HEAT TYPE: OCCUPANCY: 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 By: Date: Receipt: Approved/Date Permit $265.25 LYK 04/25/12 131674 Plan Check $172.41 LYK 04/25/12 131674 State Building Code $4.50 LYK 04/25/12 131674 Total: $442.16 Jefferson County Building Diion Permit Num Applicant: BUILDING PERMIT INSPECTION APPROVALS applicable Code: 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 FINAL INSPECTION _- I,Z 19y____ FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED THIS PERMIT IS VALID FOR ONE YEAR .,i,.gON coo JEFFERSO OUNTY • 49 , W •;,, DEPARTMENT OF COMMUNITY DEVELOPMENT `' -'\ `� 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax 'QS o ww.co.jefferson.wa.us/commdevelopment 1INOS w Master Permit Application MLA: KO M( (. 1 1 Project Description (include separate sheets as necessary): REMOVE AND REPLACE 38 SQ COMP. ROOFING. NO PLYWOOD REPLACEMENT Tax Parcel 821334096 Property Number: Size: (acres/square feet) Site Address and/or Directions to Property: 266 Moondance Ln, PORT LUDLOW 98365 Property Owner(s)of Record: Rowell Campbell Telephone:360.437.0222 Fax: email: Mailing Address: 266 Moondance Ln,PORT LUDLOW WA 98365 Applicant/Agent(if different from owner): NORTHWEST PERMIT INC. Telephone: 360-945-2787 Fax: 360-945-2091 email: NAIDA@NWPERMIT.COM Mailing Address: 1345 GULF RD,POINT ROBERTS WA 98281 What kind of Permit?(Check each box that applies ❑Building ❑Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit ❑Conditional Use[C(a),C(d),or C]** ❑Single Family ❑Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home ❑ Modular ❑Special Use(Essential Public Facilities)** ❑ Commercial* ❑ Boundary Line Adjt¢�n ---- ❑ Change of Use ❑Short Plat** `1 I r-, I Ii �/ 1l_, ❑ Address ❑Road Approach ❑ Binding Site Plan** ,' ❑ Home Business ❑Cottagelndustry ❑ Long Plat** ❑ Propane ❑ Planned Rural Residential Development.(PRRD)/Amelnji rts** ❑Sign ❑Plat Vacation/Alteration**❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisio. ❑Stormwater Management ❑Shoreline Management Substantial-Dovel�ent- -1 ❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Varianc4-1 rR':°CI lj •11 ❑Temporary Use ❑Comprehensive Plan/UDC/Larid`1 si:I litifA r'' nt ❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑Tree Vegetaion Request *May require a Pre-Application Conference **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 NORTHWEST PERMIT INC. to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE iii-L"-ii1 1 �1 11jDate: 474 --/"51 -?i9/2:-.--- 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 it's 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 entry to Jefferson 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 be assumed unless the applicant informs the County in writing at the time of the application that he or she want rior notice. Signature: /. j (j- Cw�✓/!Il Date: V---"/'lb 2 O/�� 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,she or it holds individual and non-transfer le responsibility for a herig to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: ,J'� �11.1/' Date: 9- -- /454 ^ 2-0/2— C:\Documents and Settings\caral\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.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: THE HOME DEPOT AT HOME SERVICES ( 800)381-5699 ( ) MAILING ADDRESS: 140 County Line Rd#101,Pacific WA 98047 EMAIL: 140 County Line Rd#101,Pacific WA 98047 CONTRACTOR'S LICENSE WAINS NUMBER: HOMED**972RQ NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New CJ Wood Existing: I J Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System Li Repair Li Masonry SEP Permit# Li Demolition I i Other: Bedrooms: Water Supply: Existing: Setback: Cl Private well ❑ Two Party Type of Heat: Proposed: I I 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 yoi? e t-o S ? Y AV - I If this is a Propane Tank and/or Appliance Installation permit, mark all items below�I'1a1�ip � ❑Underground Tank (`]Above ground Tank Size of Propane Tank; . : l� I ❑Heat Stove 0 Cook Stove 0 Woodstove 0 Fireplace InsertHot1 I p 0 Water Tank ❑Pellet Stove 0Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / N6 I I I When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildiri ,,611 property lines,tank location and size, distances from the propane tank to all property lines',Ikiildings and septic t yctcm components, including the reserve area. LEFFERSOJ COUNTY L)FPT OF COMMUNITY DEVr OPMENT Square Footage Current Proposed For Office Use Only Amount Revision _ Main Floor Heated EH Bld App Review. 2n°Floor Heated Consistency Review. Other Heated Base fee: a . a5 Mezzanine Additional Section: Heated Basement Plan Check fee: \12 . Li Unheated Basement State Surcharge fee: - l 50 Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: Other TOTAL: $ L f'- -Z , 1 L Receipt Number: 1 3-l{7L-1 Cash/Check Number: 8`1 ESTIMATED COST(REQUIRED) Date: .Fair market value of all labor and materials foundation to finish I5, ,L6tl3 m Initials: --- C:\Documents and Settings\caral\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-19-2006.doc