HomeMy WebLinkAboutBLD2012-00240 tILDING PERMIT APPLICAIN BLD12-00240
Jefferson County Department of Community Development Review Type:
621 Sheridan Street Port Townsend, WA 98368
PERMIT*: BLD12-00240
SITE ADDRESS: 71 CHICKADEE LN Received Date: 8/6/2012
QUILCENE, 98376
OWNER: CARL F SMITH
PO BOX 868 PHONE: 360 765 3692
QUILCENE WA 98376-0868
SUBDIVISION: QUILCENE BAY VISTA
PARCEL NUMBER: 701205007 Block: Lot: 7
Section: 20 Township: 27 N Range: 01 W
CONTRACTOR: OWNER/BUILDER
PHONE:
REPRESENTATIVE:
PHONE:
PROJECT DESCRIPTIOt ROOF OVER EXISTING DECK
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION 1,000.00 MAIN:
CODE EDITION: 2009 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER:
CONST TYPE: GARAGE: SHORELINE
DECK: SETBACK:
SEWAGE DISPOSAL: BANK HEIGHT:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid Bv: Date: Receipt:
APP'
Permit $38.75 LYK 08/06/12 135072 E `
Plan Check $25.19 LYK 08/06/12 135072 rr __
State Building Code $4.50 LYK 08/06/12 135072 AUG �P 202
Total: $68.44 Jefferson County Plannin f
& Building Department
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Jefferson County Building Division Permit Num110
BLD12-00240
Applicant: SM
BUILDING PERMIT INSPECTION APPROVALS Applicable Code: 2 019 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
Framing
FINAL INSPECTION I)_L . 1 2
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
4inisiiii46, JEFFERSON.UNTY •
A DEPARTMENT OF COMMUNITY DEVELOPMENT
` '4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�qp� www.co.jefferson.wa.us/commdevelopment
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Master Permit Application MLA: 00 (fl(A-
Project Description(include separate sheets as necessary): ,,/
C-0/Z 5f'f C.7 CovC'J- over- e i 5.-6k 9_ deck
Tax Parcel Number: 70/ 2 U 5—Uo 7 Property Size: S- acv-c5. (acres/square feet)
Site Address and/or Directions to Property:
7/ C,LIi c/LCc dfE L4rt e , v!/ceK e ,1 9 7‘
Property Owner(s)of Record: (Rr/ /= .}'t l tit
Telephone: 36 76.> 3 6`T 2 Fax: email: 0.er(6Smt l 4140rrl°a//•4444(
Mailing Address: P. L0. / i X kC r azit/cepte / w/¢ Y cY 7G
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit? (Check each box o ,� ='•- Segregation
l $wilding \4 tiiii I. • - s Stewardship Plan
❑ Demolition Permit I 0 Vail.' -1 inor, Major or Reasonable Economic Use)
C Single Family 0 Garage -d/Detached 0 Con.' :I Use[C(a), C(d),or C]**
❑ Manufactured Home ❑ Modular n F iscr • : "D"or Unnamed Use Classification
❑ Commercial* I �u' peel. •.e(Essential Public Facilities)**
• Change of Use ( i 0 Boun . Li e Adjustment
g l i I v1
❑ Address ❑ Road Appr ch' ort Plat**
❑ Home Business R30Pd CO
❑ Cottage In ustry �jpqippg Site Ian**
❑ Propane �__�EPT.OF COMMUNITY D ong lat**
❑ 31gn 0 Planned kural Residential Development(PRRD)/Amendments**
❑Allowed"Yes" Use Consistency Analysis ❑ Plat Vacation/Alteration**
0 Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
❑ 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:
A,4,71e- 1`PIow" 1
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date: SA/0'/7--
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 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/tilt he or -wa t _
Signature: Date: i
6 Zv!Z.
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-transferabll,/ sponsi '.y f r 's ng to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: 2 Date: 7/`/2-0/Z
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
BUILDER STATEMENT
The signer of this statement does he rtify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assumi , e respo ili e eneral Contractor for the proposed project.Signature: / Date: 7/9 / /?—
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL.:
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE
( ) FAx:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New X Wood Existing: 3 C Sewer
C Addition E. Steel Proposed: -- Bank C Community System
›`Alteration/Remodel C Concrete Total: 3 _ Height: g Individual System
❑ Repair ❑ Masonry — SEP Permit# _
C Demolition ii Other: Bedrooms: Water Supply:
Existing: 2 Setback:
Type of Heat: Proposed: — Private well - Two Party
6 /e lee 11-,C Total: 2 ❑ e oc
Namme 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:
1 Underground Tank 1 Above ground Tank Size of Propane Tank:
Heat Stove I Cook Stove 1 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:
2 °Floor Heated Consistency Review:
Other Heated Base fee: 3 I�
Mezzanine Additional Section: I✓
Heated Basement Plan Check fee: a/5. A
Unheated Basement State Surcharge fee: ..4_:__
Other Unheated. Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other
Cot/ev'D N eV— TOTAL: $(og `T
.e Xt $flocs G ' /'— Receipt Number:
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: Q
'Fair market value of all labor and materials foundation to finish Ct_" „{
(f ovv Initials: f
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc