HomeMy WebLinkAboutBLD2011-00271 ILDING PERMIT APPLICA1N BLD11-00271
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00271 Received Date: 10/4/2011
SITE ADDRESS: 1340 DABOB RD
QUILCENE, 98376
OWNER: MARK R POKORNY PHONE: 360-301-4533
TAMARA S POKORNY •
1340 DABOB RD
QUILCENE WA 98376-9727
SUBDIVISION: Block: Lot: T19+
PARCEL NUMBER: 801212004 Section: 21 Township: 28 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr DEMO EXISTING BARN/SHOP
TYPE OF WORK GAR SQUARE FOOTAGE:
TYPE OF IMP DEM MAIN:
VALUATION ADD'L: HEAT TYPE: UH
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: 1 PWELL
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: j1tal:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $71.00 LYK 10/04/11 128200 APPROVED
State Building Code $4.50 LYK 10/04/11 128200
Total: $75.50 Nov 03 'BM
Jefferson County Planning
&Building Department
I
• w
---0.GION CL, - Olympic Region Clean Air Agency
''?ti../ p\�` 2940-B Limited Lane NW
° 74,x;; Olympia,WA 98502
I , (360)539-7610•FAX(360)491-6308
' +: � t Port Angels office(360)417-1466 Demolition
P e t
'' ORCAA ,�; Raymond Of (360)942-2137 r R o
[ ] Commercial Structure—Permit fee: $60.00—10 working day wait period •
' Owner occupied residential dwelling—Permit fee: $35.00—Prior Notice`
vt/it ys#- kArm
PROPERTY OWNER '• 0 rna i 1•co-14'1
Name: Phone: (3Gti alb —i rie Friii l•' bt ,
• • /A tiv 1G 4) To i Po tcolro y - FAX: : ( )' Mobile:'(34)'3 0 L—1-1,C33
Mailing Address: Ci •: State: Zip
• P 1340 e6h la u`,lceoe -v l-.,. B3-°76v
Site Address: City: State - Zip:
DEMOLITION CONTRACTOR -Check if same as property owner information
Business Name: Phone (. ) a
F r l-
FAX: ( )
Onsite Contact Phone: ( - ) Mobile: ( )
FAQ ( ) .
Mailing Address: City: State:.: Zip:
DEMOLITION INFORMATION -
- #of Structures being demolished Start Date: Completion Data
l 4- co(/ 11-0-1411--. 1 -/1/ l k e r' k 4-e-v- '-1 t /Ck-
Asbestos present _Yes Oro - Survey.attached L/Yes No- Has-all identified-asbestos been
removed Yes No' N/Ar
• DEMOLITION PROJECT CATEGORY
Complete Demolition
-[ ]Training Fire—Fire Agency:
[ ]Renovation,Alteration,Remodeling,Maintenance,or other Construction -
[ ]Emergency—Additional Fee of$50.00 (must be accompanied by GovernmentIln erect Declaration-Comimercial only
! - ECE VF,
Heave read and will abide by the conditions set forth in this permit and an ,• , _ .. •
• •• , , b3'ce lY
that all identified asbestos has been removed and the information in thiSa Jlication and,supplem-, .- oats
described herein is, to the best ofmplcnowledge,accurate and complete ii --OCT. - 1 9 2011
JEFFERSON COUNTY
• , DEPT OF COMMUNITY
Applicant Name Signature -• Date -
Dateptettp Received Payment Info. Approved • Asbestos Permit
[ 1 Cash - . - [ ] Disapproved - Permit# ASB0O
I D
[ ]'Check # �� f Demolitio ?emit
OCT 12 2011 [ ] Credit Card Review date:/t /h/ I f. Permit# I I DEMOOP
Receive dater- /I1/t I.. Reviewed by: t -
se _igeng Use Only Agency Use Only Agency Ule Onh.
-10/21/0 OVER
i
("oN eat JEFFERSOI1UNTY 6
' DEPARTMENT OF COMMUNITY DEVELOPMENT
` P4 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: t\ 0101 2f'D (b
P ect Description(include separate sheets as necessary):
1
trYi 0 eAST EnfOtisp
Tax Parcel Number: so ( 2-(Z 001.1 Property Size: 27 CcGtl,e5 (acres/square feet)
Site Address and/or Directions to Property:
(3 q0 nabob Raztd & IAA toney WA- p y37(#
Property Owner(s)of Record: (A/LarIG Din p('(d Wt k I(m Pa k a rn y
Telephone: 3teO/AD/— 'I'533 Fax: email: ✓Q�l�Eyr16GI r i'i _
Mailing Address: Savii e a 5 abo ire, q pyl,Q.l 1 • C-0401 Applicant/Agent(if different from owner): U
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregatio C-' C V `
w ing ❑Critical Areas Stewards I�n
Demolition Permit ❑Variance(Minor, Major - sonable Eco omit Use)
❑Single Family ❑ Garage Attached/Detached ❑Conditional Use[C(a),C ,d or C)(}€1 4
❑ Manufactured Home .❑ Modular - ❑ Discretionary"D"or Ur • Use Classification
❑ Commercial* ❑Special Use(Essential ` Facilities)**
❑ Change of Use ❑ Boundary Line Adjust ent JEFFERSON COUNTY
❑ Address ❑ Road Approach ❑Short Plat** DEPT.OF COMMUNITY DEVELOPMENT
❑Home Business ❑Cottage Industry ❑Binding Site Plan**
❑ Propane ❑ Long Plat**
❑Sign • ❑ Planned Rurai Residential Development(PRRD)/Amendments** .
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions**
❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development**
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land 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 inspectio Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the a li ' that he or she ,an prior notice. G,
�ignatu t ._.,. - /.Date: 72 f
The action or actions Applicant will undertake -s 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 complia with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and no - n fe le responsib" dhering to and complying with the ESA. The Applicant has read this disclaim? and sig s and dates it below.
Xign Date: 777.# ,, ,
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 responsibi • e General Contractor for the proposed project.
X.fignallilit /,,- __,/-,.. t _ Date: �e/..--0//
GENERAL CONTRACTOR OR MANUFACTURED*ME INSTALLER: PHONE: FAX:
( ) ( )
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:
O New 0 Wood Existing: ❑ Sewer
O Addition 0 Steel Proposed: Bank 0 Community System
O Alteration/Remodel 0 Concrete Total: Height: ❑ Individual System
O Repair 0 Masonry SEP Permit#
O Demolition 0 Other: Bedrooms: Water Supply:
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 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:
I Heat Stove 1 Cook Stove i Woodstove 1 Fireplace Insert I 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 fice U e-Onjy;': Amount- vis on .
-Main Floor Heated EH BId App Review: D3 2 t�n
"d Floor Heated Consistency Review:Floo
Other Heated Base fee: ri'
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement -` State Surcharge fee: 4
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $ ri C)C
Receipt Number: la $aW
Cash/Check Number: DCI
lq ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish
Initials:
GAP ermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
PERMIT
EXPIRATION NOTICE
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
March 14, 2014
MARK R POKORNY
TAMARA S POKORNY
1340 DABOB RD
QUILCENE WA 98376-9727
RE: SUBJECT: PERMIT TO EXPIRE - NOT RENEWABLE
SITE ADDRESS: 1340 DABOB RD
PERMIT#: BLD11-00271
LEGAL DESCRIPTION: BLOCK: LOT: T19+
PROJECT DESCRIPTION: DEMO EXISTING BARN/SHOP -SEE BLD11-272
DEAR MARK POKORNY
PERMIT# BLD11-00271 WAS ISSUED BY THIS DEPARTMENT ON 11/28/2011 , WAS VALID FOR ONE
YEAR AND IS NOT RENEWABLE. According to our records, a final inspection has either not been
scheduled or has not been passed.
TO SCHEDULE A FINAL INSPECTION, CONTACT THE DEPARTMENT OF COMMUNITY DEVELOPMENT
INSPECTION HOTLINE AT 379-4455 and leave your request after the recorded message.
In the event a final inspection is not passed, the inspector will give you a written notice of required
corrections. You must call for a re-inspection to receive final approval.
A FINAL INSPECTION MUST BE SCHEDULED BY 4/14/2014.
Please contact the Department of Community Development(360) 379-4450 with any questions.
Sincerely,
Permit Tec nician
cc: file
\\tidemark\data\forms\F BLD_pro_exp_ntc.rpt 3/14/2014
SEP-23-2011 04:25P FROM:WITHERIDGE 3603850584 T 859401 P.1
NORTHWEST ASBESTOS CONSULTANTS
Surveys, Inspection, Sampling
AHERA Building Inspector / Mgmt. Planner
EPA Certification WAMOA-0042
406 Reed St.Port Townsend,WA 98368
northwestasbestosconsultants @cablespeed.com
360-385-0584
pate; 9/23/11
Job Location: 1340 Dabob Rd.
Quilcene,WA 98376
Contact: Tamara Pokorny
1340 Dabob Rd.
Opilcene,WA 98376
Subject: Demolition
Inspector: Bob Witheridge
AHERA - Building Inspector / Management Planner
WAMOA-0042-1022201002
Expires - 10/22/11
D kcEuvEr,
JEFFERSON COi 'TY
DEPT OF COfh NUi`ITy F'f" ,r^ gT
SEP-23-2011 04:25P FROM:WITHERIDO 3603850584 T 859401 P.2
. v
$cope of work
1) Good faith inspection for asbestos containing building materials (ACBM).
2) Survey, sample and record suspect materials.
3) Report to owner with results.
,ispection Report
The inspection started with a visual survey looking for Asbestos Containing Building
Material (ACBM).
This single story structure approx. 700 sq. ft. had combination of wood and cement
floors. Exterior wood siding with wood and tin roof.
No suspect ACBM.
Cold storage building approx. 88 sq. ft. had cement floor, wood frame and exterior wood
siding with tin roof.
No suspect ACBM.
SEP-23-2011 04:25P FROM:WITHERIDGE 3603850584 T0:3859401 P.3
Summary of Inspection
All asbestos containing building materials with a reading greater than 1% is
considered a hazardous material if disturbed.
During demolition it is possible that additional suspect asbestos containing building
material (ACBM) may be found. Should such suspect material be discovered an AHERA
certified inspector will have to sample and test the material to prove it is of non-
asbestos.
Northwest Asbestos Consultants is not responsible for identification of hidden
materials that are not identifiable with reasonable diligence.
Thank you,
Bog,.bat4Watte
Bob Witheridge, E.F.M.
SEP-23-2011 04:25P FROM:WITHERIDCE 3603850584 TO: 859401 P.4
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DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD11-00271 Received Date 10/4/2011
SITE ADDRESS: 1340 DABOB RD Issue Date 11/28/2011
QUILCENE, 98376
APPLICANT: MARK R POKORNY PHONE: 360-301-4533
TAMARA S POKORNY
1340 DABOB RD
QUILCENE WA 98376-9727 T19+
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 801212004 Section: 21 Township: 28N Range: 01W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, MARK R POKORNY PHONE: 360-301-4533
if different: TAMARA S POKORNY
1340 DABOB RD
QUILCENE WA 98376-9727
PROJECT DESCRIPTION: DEMO EXISTING BARN/SHOP
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 11/28/2012.
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
I:\F_BLD_Permit_Propane.rpt 10/29/19
6` °{ JEFFERSON COUNTY
',r �.. DEPARTMENT OF COMMUNITY DEVELOPMENT
gSff I N G-Cc
Date: /i-//'Time Received: 'Q.5— Opm Mon. Wed. Thur. Fri.
Date: / 6`j=/5`
BL D: 1 / -A7/ Contact Name: ileitAff
Owner: Contact Number: 360 3 0 if `7(533
Address: /t3 '-1p ,a4130,q 206 7.206f , gift,TVO
Notes:
Foundation Plumbing Framing Propane Tank Mechanical
Setbacks Under-ground Framing Under ground Furance
Footing Rough In Air Seal Above ground Gas
_
Sternwall Hydronic Exterior shear Exterior lines v Oil
�Y�
Straps Hot Water Htr Interior shear Interior lines Ducts
Post Hole Ventilation Appliance
Underfloor Gas/Wood stove
Man-Homes Insulation
Final Inspection \
Setbacks Floor
Foundation Wall Address Posted
Block &Tile Ceiling
/
��w, ON cb°> JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
4. logfte.
N,p,/I N Ci o S
Date: Time Received: g37 AVM Mon. Tue. Wed. Thur. Fri.
�(( �� Date:
BAD: j/_01 7/ Contact Name:
Owner: Contact Number: 360 3D/ 1./c73
Address: L'" /31/p O 4460 ig 206 3,6 9cP 70
Notes:
Foundation Plumbing Framing Propane Tank Mechanical
Setbacks Under-ground Framing Underground Furance
Footing Rough In Air Seal Above ground Gas
Stemwall Hydronic Exterior shear Exterior lines Oil
Straps Hot Water Htr Interior shear Interior lines Ducts
Post Hole Ventilation Appliance
Underfloor Gas/Wood stove
Man-Homes Insulation,
Final Inspection
Setbacks Floor
Foundation Wall Address Posted
Block&Tile Ceiling
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