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Home My WebLink AboutBLD2014-00324 - MECHANICAL UILDING PERMIT APPLICA ANN BLD14-00324 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD14-00324 Received Date: 9/8/2014 SITE ADDRESS: 2280 ANDERSON LAKE RD # ,Y, CHIMACUM, 98325 OWNER: EVERGREEN COHO ESCAP RETREAT PHONE: 2481 ANDERSON LAKE RD CHIMACUM WA 98325-9795 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901101039 Section: 10 Township: 29 N Range: 1111 CONTRACTOR: C H S INC PHONE: (360)732-4585 PO BOX 518 AUBURN WA 98071-0518 Contractor's License CHSIN**979OZ Expires 9/7/2016 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI+ 120 GALLON PROPANE TANK TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP MEC MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: A •OTTADate Permit $228.00 JLA 09/08/14 151479 . n Total: $228.00 SAP 10 20f4 Jefferson Ccur. i 9c._ \\tidemark\data\forms\F_BLD_App_Bld.rpt 9/11/2014 „t47-;ON c06, JEFFERSON•UNTY S( 7 p(ca(v) - .\. r�j DEPARTMENT OF COMMUNITY DEVELOPMENT 'w ''� 621 Sheridan Street • Port Townsend •Washington 98368 / -46 360/379-4450 • 360/379-4451 Fax ‘r \ -iii qs 8TN )��0 www.co.jefferson.wa.us/commdevelopment , Master Permit Application MLA: —� Project Description(include separate she is as necessary): 1 ' X 10 ' Lo I” iri 5 k P bk- Tax Parcel Number: 9 / 1 0 I 0 "39 tDX f yy Property Size: 'Yl9 / X 7!/ / (acres/square feet) Site Address and/or Directions to Property: Property Owner(s)of Record: r'. 7 A Me ri. sv-e.,.M- -, 0'4'44 Telephone: , I , M tvve. !q e email: Mailing Address: 1,1 ci A b.„,.. .erSun b< Rol 0 JA,f,nr.e. e L.,..,-y 114 93 ; 5 Applicant/Agent(if different from owner): Telephone: Fax: — email: Mailing Address:_ _ What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation ❑Building 0 Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) ❑ Single Family ❑ Garage Attached/Detached ❑ Conditional Use[C(a), C(d),or C]** ❑ Manufactured Horne .❑ Modular • - ❑ Discretionary"D"or Unnamed Use Classification `0 Commercial* ❑Special Use(Essential P •" - " ❑ Change of Use ❑ Boundary Line Adjustm� ( C E II V I, ❑ Address ❑ Road Approach_ ❑Short Plat** t 1� ❑ -lome Business 0 Cottage Industry 0 Binding Site Plan** Propane ❑ Long Plat** ❑ oiyri ❑ Plannea kurai Residenti.l r- :lopr (PR-w,)/ ;dm; * ❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration ❑ Stormwater Management ❑Shoreline Master Progra 'x- •tion/P- u' ' ' ❑ Site Plan Approval Acvance Determination(SPAAD)* ❑Shoreline Management ` bstantial Di 6 ,'AMY ❑Temporary Use ❑Shoreline Management :rian it OF COMMUNITY DEVELOPMENT ❑Wireless Telecommunication* ❑ Comprehensive Plan/UD an. Use District Map Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑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 to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: 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 applicati at h= i ray)- wants prior notice. Signature: J''r� Date: 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-trans - :ble res•;.s'•ility for adherin. •<.•d complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: i..,_A i. . . �� . _ -- - Date: I G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc ■ 0 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: PI-IGNE: FAX: ad, , . e. , . k... .e "5 LL e. (. .00 5AI I-6 / (3GO 7yD 9 MAILING ADDRESS: I J3 1..:1 i I It, - , EMAIL: f CONTRACTORS LICENSE �.t- ` t„JA WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: f Shoreline: Type of Sewage Disposal: New ❑ Wood Existing: E Sewer ❑ Addition Ei Steel Proposed: Bank ❑ Community System Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System 0 Repair ❑ Masonry — SEP Permit# El Demolition ❑ Other: Bedrooms: Water Supply: Existing: _ Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: ❑ 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 ;BC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No - f Isis a1'ra•arre Tank-andlorA•.fiance Installation •erm it mark all items below that apply: i Underground'TRnk .I.;11., - -,-ound Size of Propane Tank: 1 2,0 i Heat Stove T Gook Stove I Woodstove i Fireplace Insert i Hot Water Tank i Pellet StoA i Other Isthis 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, <includlr ,the reserve area. a Y Squire'Footage Current Proposed For Office Use Only Amount Revision Main Floor Heated EH BId App Review: 2n°Floor Heated Consistency Review: Other Heated Base fee: 191-6 -63 Mezzanine — Additional Section: 1,v` Heated Basement Plan Check fee: Unhe.t • State Surcharge fee: Other Uln :-ted $ 2014 Pot Water Review fee: _ • Garage/Cart, ft SUBTOTAL Decks ' t itiFER0Ct1 F FMEi0f 911/Rd Approach fee: Other ,,,\ri.s-___-- V` - — TOTAL: $ c �7-00--- Receipt Number: 15/ 47e Cash/Check Number: 4 ESTIMATED COST(REQUIRED) Date: 9/00/4t_ .Fair market value of all labor and materials foundation to finish W `�"� Initials: y0 G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc CHSINC Page l of 4 • • Washington State Depar tment of kj Labor & Industries CHSINC Owner or tradesperson PO BOX 518 CASALE,CARL MARTIN AUBURN, WA 98071-0518 253-833-7220 Principals KING County CASALE, CARL MARTIN, PRESIDENT EGAN, THERESA MARIE, VICE PRESIDENT MCENROE, JOHN DANIEL, VICE PRESIDENT LILJA, NANCI LEE, SECRETARY KASTELIC, DAVID ALLEN, TREASURER C T CORPORATION SYSTEM, AGENT ESTENSON, NOEL, PRESIDENT (End: 09/21/2012) WESTBROCK, LEON, VICE PRESIDENT (End: 09/21/2012) BAKER, DAVID A, SECRETARY (End: 09/21/2012) Doing business as CHSINC WA UBI No. Business type 600 148 004 Corporation License Verify the contractor's active registration/license/certification (depending on trade) and any past violations. Construction Contractor Active. Meets current requirements. • License specialties GENERAL License no. CHSIN**9790Z Effective—expiration 09/09/2003—09/07/2016 Bond Liberty Mutual Ins Co $12,000.00 Bond account no. 58S203444 Received by L&I Effective date https://secure.lni.wa.gov/verify/Detail.aspx?UBI=600148004&LIC=CHSIN**9790Z&SAW= 9/11/2014 C H S INC Page 2 of 4 10/05/2012 11/21/2012 Expiration date Until Canceled Bond history Insurance Old Republic Ins Co $1,000,000.00 Policy no. MWZY302766 Received by L&I Effective date 09/08/2014 09/01/2014 Expiration date 09/01/2015 Insurance history Savings No savings accounts during the previous 6 year period. Lawsuits against the bond or savings No lawsuits against the bond or savings accounts during the previous 6 year period. L&l Tax debts . ..... .. .... .... ..... No L8�I tax debts are recorded for this contractor license during the previous 6 year period, but some debts may be recorded by other agencies. License Violations No license violations during the previous 6 year period. Workers' comp Do you know if the business has employees? If so, verify the business is up-to-date on workers' comp premiums. This company has multiple workers' comp accounts. Active accounts L8,1 Account ID Self Insured. 700,394-00 This business is certified to cover its own workers' comp costs. No premiums due. Doing business as CHS INC Estimated workers reported N/A L&l account representative (360)902-4817 Track this contractor Workplace safety and health Check for any past safety and health violations found on jobsites this business was responsible for. Citation issue date 09/14/2011 No violations Inspection no. 315180448 https://secure.lni.wa.gov/verify/Detail.aspx?UBI=600148004&LIC=CHSIN**9790Z&SAW= 9/11/2014 C H S INC Page 3 of 4 Location • 153 NW State Ave Chehalis,WA 98532 Citation issue date 08/26/2011 No violations Inspection no. 315093930 Location 7902 N Division St Spokane,WA 99208 Citation issue date 08/19/2011 No violations inspection no. 315054858 Location 900 E Columbia Kennewick,WA 99336 Citation issue date 07/20/2011 No violations Inspection no. 314949959 Location 900 E Columbia Kennewick,WA 99336 Citation issue date 05/04/2011 Violations Inspection no. 314618695 Location 400 Toteff Rd Kalama,WA 98625 Citation issue date 05/17/2010 Violations Inspection no. 313999716 Location 433 N Columbia Connell,WA 99326 https://secure.lni.wa.gov/verify/Detail.aspx?UBI=600148004&LIC=CHSIN**9790Z&SAW= 9/11/2014 C H S INC Page 4 of 4 Citation issue date • • 03/31/2010 No violations Inspection no. 314140948 Location 433 N Columbia Connell,WA 99326 Citation issue date 03/31/2010 No violations Inspection no. 314140955 Location 528 S Booker Rd. Othello,WA 99344 Citation issue date 03/31/2010 No violations Inspection no. 314140963 Location 3132 Rd.0 NE Moses Lake,WA 98837 Citation issue date 12/23/2009 No violations Inspection no. 313674509 Location 111 N. 9th Walla Walla,WA 99362-1721 Washington State Dept.of Labor&Industries use of this site is subject to the laws of the state of Washington. ACCess ANA t ,llin*tCnr, https://secure.lni.wa.gov/verify/Detail.aspx?UBI=600148004&LIC=CHSIN**9790Z&SAW= 9/11/2014 MECHANICAL AND DEMOLITION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD14-00324 Received Date 9/8/2014 SITE ADDRESS: 2280 ANDERSON LAKE RD #236 +fief i t' Issue Date 9/11/2014 CHIMACUM, 98325 APPLICANT: EVERGREEN COHO ESCAP RETREAT PHONE: 2481 ANDERSON LAKE RD CHIMACUM WA 98325-9795 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901101039 Section: 10 Township: 29N Range: 1W CONTRACTOR: C H S INC PHONE: (360)732-4585 PO BOX 518 AUBURN WA 98071-0518 Contractor's License CHSIN**9790Z Expires 9/7/2016 OWNER, EVERGREEN COHO ESCAP RETREAT PHONE: if different: 2481 ANDERSON LAKE RD CHIMACUM WA 98325-9795 PROJECT DESCRIPTION: 120 GALLON PROPANE TANK 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 9/11/2015. REQUIRED INSPECTIONS: Installation per Manufacturer Specifications/CO2: Tank/Line/Appliance: 1 b 1 / 11 Final Approval: r kt) -7411 BUILDING INSPECTION HOT-LINE 379-4455. REQUESTS MUST BE RECEIVED BY 3 PM THE DAY BEFORE THE INSPECTION IS NEEDED. Office Hours 9:00 a.m. -4:30 p.m. Monday-Thursday HOT LINE AVAILABLE 24 HOURS A DAY \\tidemark\data\forms\F_B LD_Permit_Propane.rpt 9/11/2014 4/ 0 ' 9 7 ) / Will rldlifun ).. L gci It4I 1 sky . col \oi o9 1 ! C-- ,■.''''.--- it . , I j I -1 I---- r- P- I N11 I , I 1 I 1 I . 4 L . 1 1 'ff,' OEUVI I 11) SEP - 82014 j \L [ JEFFERSON COUNTY _ DEPT.OF COMMUNITY DEVELOPMENT 1 --.9 1