HomeMy WebLinkAboutBLD2012-00260 •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD12-00260 Received Date 8/22/2012
SITE ADDRESS: 8417 FLAGLER RD Issue Date 8/30/2012
NORDLAND, 98358
APPLICANT: ELAINE P SEIKE/LINDA SEIKE/CAROL RAMEY PHONE: 206-779-5958 DC
DONNA SEIKE-SETIJONO
6128 147TH AVE SE
BELLEVUE WA 98006-4342 8
SUBDIVISION: GLENNAN SUBURBAN ACRE Block: 4 Lot:
PARCEL NUMBER: 953700413 Section: 29 Township: 30N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, ELAINE P SEIKE/LINDA SEIKE/CAROL RAMEY PHONE: 206-779-5958 DON'
if different: DONNA SEIKE-SETIJONO
6128 147TH AVE SE
BELLEVUE WA 98006-4342
PROJECT DESCRIPTION: DEMO EXISITNG SFR
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 8/30/2013.
REQUIRED INSPECTION:
FinalApproval:
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_Permit_Propane.rpt 8/30/2012
WILDING PERMIT APPLICATION BLD12-00260
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
STT#: BLD12-00260 Received Date: 8/22/2012
EMDRESS: 8417 FLAGLER RD
NORDLAND, 98358
OWNER: ELAINE P SEIKE/LINDA SEIKE/CAROL RAMEY PHONE: 206-779-5958
DONNA SEIKE-SETIJONO DONNA/HERMAN
6128 147TH AVE SE
BELLEVUE WA 98006-4342 GLENNAN SUBURBAN ACRE
SUBDIVISION: Block: 4 Lot: 8
PARCEL NUMBER: 953700413 Section: 29 Township: 30 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: HERMAN SETIJONO PHONE: 206-779-5958
6128 147TH AVE SE
BELLEVUE WA 98006
PROJECT DESCRIPTIOI DEMO EXISITNG SFR
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM MAIN:
VALUATION ADD'L: HEAT TYPE:
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: 05783
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: _T { —
Routing Date:
g-Z7-IZ
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $74.00 LYK 08/22/12 135133 APPROVED
State Building Code $4.50 LYK 08/22/12 135133
Total: $78.50 AUG 30 2012
Jefferson County Planning
& Building Department
11fi,dcmar4\,Jofo\fnrmc\C RI n n.,., ,r,+ A/77/7(117
• •
4: :Ar
�� G1oNCt y. Olympic Region Clean Air Agency
/'~�� .. ^` `,Cf\ 2940-B Limited Lane NW
-' iCtt.\ Olympia,WA 98502
` / ,` Poet ngeles o0•FAX(360) -14 6308 Demolition Permit
, o' Port Angeles office(360)417-1466
.'\,� ORCAA , Raymond Office(360)942-2137
* �..4,40t•fErEENsor. ,,,$Ds. o�- www.ORCAA.org
f✓j Owner occupied residential dwelling—Permit fee: $35.00—Prior Notice-Nonrefundable
[ ] Other Structures—Permit fee: $60.00—10 working day wait period-Nonrefundable
PROPERTY OWNER .
Name: Phone: (L155) 626S 16,53 Email: )5t`1 ((
i o^l"eCe•vects7./Jt
S�NNA 5MIKF ,F-"RJc o FAX: (70C) 32 _1476• , Mobile: (4.2S) yt(SR61. -3
Mailing Address: City,:„ State: Zi •
•
�i f 28 l�71f/�VE 51= jLLtzJU�z WA-- zip:
S e Address: City: St te• Zip:
i6117 FLI LLwc feoAP _ Nop U- C) AJ4 7 e3$?
DEMOLITION CONTRACTOR IN/Check if same as property owner information
Business Name: Phone: ( ) Email:
FAX: ( )
Onsite Contact: Phone: ( ) Mobile: ( )
FAX: ( )
Mailing Address: City: State: Zip:
DEMOLITION INFORMATION
#of Structures being demolished: Start Date: Completion Date:
ON/E_. i o C3 . 1P2u44N/10
Asbest s,Present Yes _ No �S ' y attached _Yes No Has all identified asbestos been
C. 4 C '1�Y� $o IQx—, Ltd rebt4ovd 10r101`-e removed _Yes Z.No
I t r' .-- /}Gl4A 1/V1(I MI- 4f 5+)cbe0C•1(5S Wm/0
DOLITION PROJECT CATEGORY
Complete Demolition
[ ]Training Fire—Fire Agency:
—
[ ]Renovation,Alteration,Remodeling,Maintenance,or other Construction I)
[ ]Emergency—Additional Fee of$50.00(must be accompanied by Government drfaeTe t1 galy)
I have read and will abide by the conditions set forth in this permit and any addendum thereto. I do hereby certify
that all identified asbestos has been removed and the information in this application and supplemental data
described herein is,to the best ofmy knowledge,accurate and complete.i ; .
J
li f FCRSON.rO!,;^,ilY
donna Seiw/((- Id(' ^ono Ornm.4 ,6(.. ..., 4-4�J/z
Applicant Name V Signature Date
Dft5 rlpplicatio�r,R�efeiyed Payment Info. [ ] Approved Asbestos Permit
i-t'4,r�.j�+..�' s V k--LI [ ] Cash s,ue [ ] Disapproved Permit# ASBOO
[ heck: # ._�I 1.0 Demolitio enmit
I 2 7' 2O1Z [ ]Credit Card Review date:_/_/_ Permit#I DEMOS �
JUN
Receive dat _ap Reviewed by:
1 s _PC 4nLyik _ Agency Use Only Agency Use Only Ageng Use Only
48/1i i '44.'''..1 �`I OV R
kft7i 10:0-- O er/`JJ -P-a-Ad d02114-0 r/Z6//Ste,/y `^Ar
45M JEFFERSON•UNTY •
W A DEPARTMENT OF COMMUNITY DEVELOPMENT
'' 4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
' p'ti www.co.jefferson.wa.us/commdevelopment
mue,
Master Permit Application MLA: ['0
Project Description(include separate sheets as necessary): •
Ifi(pLI6-1 lz�clS-TNG `�6iJGLca rAwtlLy P2S,f7E-AlC
Tax Parcel Number: E 5' 3 70O 4 13 Property Size: , 87 @craj/square feet)
Site Address and/or Directions to Property: 8 4 17 FLAG t.FQ eP. N ORDut00i MJA a YY35 If'
• ,
Property Owner s)of Record: E/A1J1E S*tr-F' _ LIND& StclKi i CA1oL RAmay, Do&PJA Setri' -5r'T,J e.10
Telephone: (2abS 77q 5 4 76> Fax: (2o6)3 2q -4 766 email: NFIe+44/145 pA1AlepNe•/Jo7 ,
Mailing Address: 6.12ty 14 77.( 4t/c SE, avi-cevVE„ Wq 1 P06-(
Applicant/Agent if different from owner): HEIN-t 5�71 Jo*J 0
Telephone:C�D 779^ SB Fax: ?b 32q- 4 766 email: iipp4A,J3 ei4k1eetc •.vh7
Mailing Address: 6•I 26' -/47 74 ft z .5E, 66u you/ IV A eiSa0-4.
What kind of Permit? (Check each box that applies ❑ Lot or Road Segregation
Ihuilding ❑ Critical Areas Stewardship Plan
BeDemolition Permit El Variance(Minor, Major or Reasonable Economic Use)
I"Single Family 0 Garage Attached/Detached El Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .0 Mcdulkr 0 Discretionary"D"or Unnamed Use Classific
•
❑ Commercial* 0 Special Use(Ess • *t.k /7
L Change of Use 0 Boundary Line A ju V./❑ Address 0 Road Approach_ 0 Short Plat** I
❑ Home Business ❑ Cottage Industry 0 Binding Site Plan ,)
❑ Propane ❑ Long Plat** 1 ET ) \❑ Sign ❑ Planned lkural Residentl D /Arl nts**
El Allowed"Yes" Use Consistency Analysis ❑ Plat Vacation/Alteration"'`
CI Stormwater Management ❑ Shoreline Master Pregr visions**
❑ Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Manage ent SubstaKiiikb /k1T
❑Temporary Use ❑ Shoreline Manager cent Verfan OMMUNI
❑Wireless Telecommunication* 0 Comprehensive PIan1C16C/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 ❑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 FIE ietvfA1 J <5@7i jc7.0-3 to act as my agent in matters relating to this application for er it(s).
OWNER SIGNATURE ��' 9- Date: •o''7 lY Z(/L
By signing this application form,the owner/agent attests tat 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 that he or shed wantt prior ti e.
Signature: l.,c/,t.�i(t.K v ....T.....T. Date: J f - G, /1 (Z
The action or actions Applicant will undertake as a r ult 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-transfe axle responsibility forrr adherin to and complying with the ESA. The Applicant has read this disclaimer and signs and ates below.
Signature: Yl/Y�-��c GCc ` Date: Izif'1�//� cP 2f I 1
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master 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: J�.�-fl1/V1/L &. 6vy` 1--er Date: 4 ° /1— CY/24 // Z
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: l FAX:
Pr5Q Pill 6 ( ) ( )
MAILING ADDRESS: EMAIL.:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New Z Wood Existing: E Sewer
C Addition C Steel Proposed: Bank ❑ Community System
C Alteration/Remodel ❑ Concrete Total: v Height: C Individual System
Repair C Masonry SEP Permit# _
C Demolition C Other: Bedrooms: Water Supply:
Existing: I Setback: C Private well E Two Party
Type of Heat: Proposed: ❑ Public
ri.r',--I , Total: V 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:
1 Heat Stove i Cook Stove i Woodstove i Fireplace Insert i 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 j l b C,`>F EH Bld App Review: C��
2`d Floor Heated Consistency Review: _•l[_
Other Heated Base fee: rrii
Mezzanine Additional Section: '_ ___a
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee: O
t0c. ,,r -.5
Other Unheated' Pot Water Review fee: -- -
Garage/Carport SUBTOTAL
4Q-0
Decks 911/Rd Approach fee:
,—o --
Other TOTAL: $ 'IS .50
Receipt Number: I
Cash/Check Number: Co I
ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish 2
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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