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
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