HomeMy WebLinkAboutBLD2012-00148 • •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD12-00148 Received Date 5/8/2012
SITE ADDRESS: 581 LUDLOW BAY RD Issue Date 8/16/2012
PORT LUDLOW, 98365
APPLICANT: NORMAN R KLOUZAL PHONE: 360-509-1342
KATHRYN B KLOUZAL
2 RUBERTS SPUR RD
REPUBLIC WA 99166-9572 22
SUBDIVISION: LUDLOW BEACH TRS 2 Block: Lot:
PARCEL NUMBER: 969000002 Section: 16 Township: 28N Range: 01 E
CONTRACTOR: SOUTH SHORE CONSTRUCTION PHONE: (360) 275-0818
230 E HILLSIDE DR
BELFAIR WA 98528 ((3510l
Contractor's License SOUTHSC016NL Expires 3/13/2014-6256
OWNER, NORMAN R KLOUZAL PHONE: 360-509-1342
if different: KATHRYN B KLOUZAL
2 RUBERTS SPUR RD
REPUBLIC WA 99166-9572
PROJECT DESCRIPTION: DEMO EXISTING 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 8/16/2013.
REQUIRED INSPECTION:
FinalApproval: "" l / )3
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
\\tidemark\data\forms\F_BLD_Perm it_Propa ne.rpt 8/16/2012
•UILDING PERMIT APPLICA4N BLD12-00148
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00148 Received Date: 5/8/2012
SITE ADDRESS: 581 LUDLOW BAY RD
PORT LUDLOW, 98365
OWNER: NORMAN R KLOUZAL PHONE: 360-509-1342
KATHRYN B KLOUZAL
2 RUBERTS SPUR RD
REPUBLIC WA 99166-9572 LUDLOW BEACH TRS 2
SUBDIVISION: Block: Lot: 22
PARCEL NUMBER: 969000002 Section: 16 Township: 28 N Range: 01 E
CONTRACTOR: SOUTH SHORE CONSTRUCTION PHONE: (360) 275-0818
230 E HILLSIDE DR
BELFAIR WA 98528
Contractor's License SOUTHSC016NL Expires 3/13/2014
REPRESENTATIVE: SOUTH SHORE CONSTRUCTION PHONE: 360-509-1342
230 E HILLSIDE DR
BELFAIR WA 98528
PROJECT DESCRIPTIOP DEMO EXISTING M/H
TYPE OF WORK MOB SQUARE FOOTAGE:
TYPE OF IMP DEM MAIN:
VALUATION
CODE EDITION: 2009 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER: SHORELINE
CONST TYPE: GARAGE: SETBACK:
DECK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: 1PWELL
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total:
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Permit $74.00 LYK 05/08/12 131710 APPROVED
State Building Code $4.50 LYK 05/08/12 131710
Total: $78.50 AUG I(p 2012
Jefferson County Planninc
& Building Department
06/14/2012 11:14 3602756256 RICH MOORE PAGE 62/06
• •
.-R6610fi ,i.,. Olympic Region Clean Air Agency
/mk,,,,,, 1 2940-B Limited Lane NW
l 7% Olympia,WA 98502
i -: (360)539-7610•FAX r60)491-6308
ie ; Port Angeles office(360)417-1466 Demolition Permit
'I�o RCAA j, Raymond Office(360)942-2137
s.'$ee. �.v►,: w.ORCAA.org
[; Owner occupied residential dwelling—Permit fee: $35.00—Prior Notice-Nonrefundable
f] Other Structures—Permit fee: S60.00—10 working day wait period-Nonrefundable
[ ) Emergency Fee$50.00—must be accompanied by Government Ordered Declaration(otlier structures only)
PROPERTY OWNER
1 Name: Phone 6U1437-2510 -Email:
Norm Klouzal Par. ( ) Mobile:( )
Mai ling Address: City State: I Zip:
581 Ludlow Bay Road Port Ludlow WA 98365
-Site Address: City: State: If Zip:
same as above 1
DEMOLITION CONTRACTOR[ I Check if same as property owner information.
_Busincss Name: Phone: (36a 275-0818 Email:
South Shore Construction Inc. Fax: C36a 276-6256 southshore@q.com
Onsite Contact: Phone Mobile
36d 275-0818 56u 509-1342
Richard Moore Fa..: (36d275-6256
i Mailing Address: City: Start: I Zip:
Bet-fair i 230 E.Hillside Drive B WA 198528
DEMOLITION INFORMATION
#of structures being demolished: Sari ate:, Com cAl+nn TN---•
1 ./2ex h01 r ` .— i /a
Asbestos present? M Yes C7 No Survey attached? F.T.Yes D No Has all identified asbestos been
removed? in Yes C' No
DEMOLITION PROJECT CATEGORY
riXI Complete Demolition
( )Training Fire—Fire Agency,Contact,Phone
11 Renovation,Alteration,Remodeling.Maintenance,or other Construction
I do bereft, certit that all identified atbettot bar been removed and the information contained an tbir form and
tspplemental data detcribed bsrsin it, to the belt of my knowledge, accurate and complete.
Theresa ViCbial- W .bc+� jlnwwg1. VICKIai. .1 bee Q5j1U I la.
Applicant Name(a art -IV 5.54.) Signature ( atGr)-r OP' 5•5.C•) Date
DaReceived Payment Info. [VfAPproved Asbestos Permit
CVED [ J Cash I ] Disapproved Permit# ASB00
[ )Cheek: # DemolitioPermit
AUG 1 4 2012 [" `di`Card?3S.oo Review date- `�/1 yn�b- Permit#i .DEMoo l7�,.
Receive dare:'LL// . RetSawed by- ./
�l •
a !y .retry Um Only Agony Use Only Ajency Use Only
06/12.0 a •., OVER
4 ,y� mod. JEFFERSO OUNTY
DEPARTME COMMUNITY DEVELOPMENT •
621 Sheridan Street• Port Townsend •Washington 98368
,$ y 360/379-4450 • 360/379-4451 Fax
%N www.co.jefferson.wa.us/commdevelopment
Master Permit Application ��
Project «'ption(include separate sheets as n pry): MLA: N f_ (y� -
s Alirf' _ i 6"J
Tax Parcel Number. 9 „I AP v
Site Address and/or Di - Property Size: S 7 r (acresfsquare feet)
' G /s to Property:
®GU IGc • i
Property Owner(s)of Record: 1/d dr• / Ear
0e. �^
Telephone: �� �
Mailing Address: Fax: email:
Applicant/Agent(if different from owner): u
Telephone:'��/j'��f y
Mailing Address: ;3 e, A" Fax. email: $ae'p S/t®ram Lo
What kind of Permit?(Check each box that applies
❑Building
Demolition Permit 0 Critical Areas Stewardship Plan
❑Single Family ❑Garage Attached/Det 0 Variance(Minor,Major or Reasonable Economic Use)
❑ Manufactured Home 0 Garage
ached ❑Conditional Use[C(a),C(d),or C)
❑ Commercial* ❑Discretionary,.D.or Unnamed Use C - +� i.
❑ Change of Use ❑Special Use(Essential Public F-• . 1 ��
❑ Address ❑Road Approach 0 Boundary Line Adjustment
❑Home Business 0 Cottage Industry`— 0 Short Plat
❑Propane ❑Binding Site
Plan""
❑Sign ❑Long Plat'* ""'
❑Allowed•Yes•Use Consistency Analysis 0 Planned Rural Residential Development PRRp
❑Stormwater Management ❑Plat VacetioNAft ( YArnendments*'
❑Site Planer'rogr
Approval Advance Determination(SPAAp 0 Shoreline Master program Exemption/Permit/vermit Revisions**
❑Temporary Use ) ❑Shoreline Management Substantial Development**
❑Wireless Telecommunication* ❑Shoreline Management Variance
❑Forest Practices ease of Six-Year Moratorium ❑Comprehensive Plan/UDC/Land Use District Ma
*May require a Pre-Application Conference 0 Tree VegetationJefferse CountyShoreline Master Program Map Amendment
0 Tree Request � Amendment
Please identify any other local,state or federal **II-•uires a Pre-•s•iron Conference
Permits required for this proposal, if known:
I hereby designate / Y AkeDESIGNATION OF AGENT
act as my agent in matters relating to this application for
OWNER SIGNATURE / ,.. �/' _�d �- permit(s).
By signing this application form,the ����� Date: /
Bs, its kn owner/agent attests ; ��;
knowledge. Any material falsehood or an urformtiorr rded herein,and in any attachments,is
may
her or
in this ission of a material fact made bythetrue and correctp to the bestk of
Permit being null and void. owner/agent with respect to this
(further application packet
agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,
expenses which may in any way accrue against Jefferson County as a result of or in consequence
reasonable attorneys fees and
I further agree to provide access and right of to Jefferson County of the granting of this permit
review further
and anye provide
required later iss a diri entrytaff's a.Je • and its employees,representatives or agents for the sole u
time of the •: tion that h r she ,� d right of entry will be assumed unless the applicant informs the County in application
Signature: f•r notice
I. r' writing at the
:I %' • ,
The actio or actions ignt !- - -- Date: -
endangered atin species and couldn -k!a tlesult of the issuance of this permit may negatively impact upon one or more threatened or
"Endangeredto a .. ntial'take•of an endangered species as those terms are defined in the
Species Ad"or"ESA.'Jeffe •n County makes no assurances to thefederal law known becauses the
Permit has been issued will not violate the ESA Any individual,group or agency applicant that the actions that will be undertaken
action(s)even f you are in not compliance a h the JeffeA ge cy can file a lawsuit on behalf of an endangered species this
and non-tra,_i cable County development code.The Applicant acknowledgesregarding your
pons'biiity for a. e' :to a complying with the ESA. The Applicant has read this disclaimer she s it holds individual
Signature: ' '
signs and dates it below.
AS-. �" Date: S •'
G:\Perry enter\###FORMS###\D' FORMS\,Air
Permit Application 5 29-08.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:
GENE L CONT�CTOR OR�^,NUF+CTURED HOME INSTALLER: PHONE: Fax:
c har'e.---[ 1-lOc,' e (?6J 5'7/3�/2 (3oo �/"`
?7c . '
0 !/
MAILING ADDRESS. �,/ J o `"`
3 f J _ 0d EMAIL: $'a u y-� shoo.. 4 es. 4) rD
CONTRACTOR'S LICENSE ,4' e I fG I "- ,IS I c,
a j a,r{5"v WAINS
NUMBER: SOLOrAS 0f A J NUMBER Nfieo ft core 4213037 /_.
ARCHITECT/ENGINEER: PHONE (` ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
E New D Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank 0 Community System
ri Alteration/Remodel ❑ Concrete Total: _ Height: 0 Individual System
0 Repair 0 Masonry SEP Permit# t 2- 5
❑ Demolition 0 Other: Bedrooms: - Water Supply:
pp y'
Existing: Setback: 0 Private well 0 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(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 I Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 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 r`' 1-
Main Floor Heated - EH Bid App Review: ��' '
I
2"0 Floor Heated `�
Consistency Review: MAY _ 8
Other Heated Base fee: j i
Mezzanine Additional Section: 1EfFER80N COUNTY
DFPT.OF COMMUNITY DEVELOPMENT
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: 1-1 5
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks I
911/Rd Approach fee:
Other
TOTAL $ 1�(4, .5D
Receipt Number: 1 -7
io
Cash/Check Number: 81
`-, C'
ESTIMATED COST(REQUIRED) Date: �
•Fair market value all labor and materials foundation to finish
h 00 Initials: C. -r,
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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