HomeMy WebLinkAboutBLD2013-00351 BUILDING PERMIT APPLICsON BLD13-00351
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD13-00351 Received Date: 11/6/2013
SITE ADDRESS: 191 FOUR CORNERS RD
PORT TOWNSEND, 98368
OWNER: COLEEN CAMERON PHONE: 360-385-3730
191 4 CORNERS RD
PORT TOWNSEND WA 983689367
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001333026 Section: 33 Township: 30 N Range: 01 W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**979OZ Expires 9/7/2014
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP SWAP OUT OF 250 GAL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP MEC MAIN:
VALUATION ADD'L: HEAT TYPE: PRO
CODE EDITION: 2012 HEAT BASE: HEAT TYPE: EEE
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: Approved/Date
Permit $152.00 MEB 11/06/13 145530
Total: $152.00 APPROVED
ED
NOV 0 6 2013
Jefferson County DCD
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(,1„soN co JEFFERSON COUNTY
�, DEPARTMENT OF COMMUNITY DEVELOPMENT
r' '� 621 Sheridan Street • Port Townsend • Washington 98368
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360/379-4450 • 360/379-4451 Fax
www.cojefferson.wa.us/commdevelopment
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Master Permit Application MLA:
Project Description (include separate sheets as necessary):
S 3 3 11- • -o A i Td>c a. I ( F h i_G. 6 ,r s t, (( 940 •
Tax Parcel Number: U D J 33 3(y- _(,, Property Size: w 0 1 (acres%s uare feet)
Site Address and/or Directions to Property:
1 91 I-vkr Corkers- Aci
Property Owner(s)of Record: (. `C'�t in Ca 1rne1--o
Telephone:360 3,PJ — 3--) 3 ö Fax: i email:
Mailing Address: 1 i p ra r- Go i^news �` 4 6 y T ra c.0"Yl S e el t�
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 ❑ Critical Areas Stewardship Plan
,❑ Demolition Permit ❑Variance (Minor, Major or Reasonable Economic Use)
❑ Single Family El Garage Attached/Detached ❑ Conditional Use[C(a), C(d), or Cl**
• Manufactured Horne .❑ Modular El Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities) **
G Change of Use ❑ Boundary Line Adjustment
❑ Address ❑ Road Approach_ ❑Short Plat**
O Home Business ❑Cottage Industry ❑ Binding Site Plan**
IX Propane scow owl' Tank_ ❑ Long Plat** "
• ❑ Sign ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
El Stormwater Management ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Substantial Development**
C 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
l — **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. Staff's access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the applicatio that he or s wants prior notice.
Signature: Al* _ Date: l 1 - L- )3
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-transfer-•le r-sponsibility adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: 0 -t, /__IIL' /IA Date: 1)— 4 -1?)
• •
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: 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:
New 0 Wood Existing: C Sewer
C Addition Steel Proposed: Bank E Community System
C Alteration/Remodel 0 Concrete Total: Height: C Individual System
C Repair Masonry SEP Permit#
C Demolition Other: Bedrooms: Water Supply:
Existing: _ Setback: C Private well C Two Party
Type of Heat: Proposed: C 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
If this is a Propane Tank and/or Ap iliance Installation permit, mark all items below that apply:
Underground Tank i .bove ground Tank Size of Propane Tank: aSo
lent Stove i Cook Stove Woodstove Fireplace Insect I Hot Water Tank Pellet Stove ! Other
Is this appliance being installed in a Manufactured/ Mobile Home? Yes / Nb
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
llllE S, iahi( /lull) ilit,jivaant: Lank iJ ail i IuNuf y'inn s, UUlidin9S and stalk sy.tern CGinpOi eiits,
including the reserve area.
p^dare Fee - Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review:
2`d Floor Heated Consistency Review:
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement Plan Check fee:
—
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $
Receipt Number: i i( c5-30
Cash/Check Number: ,-2. Q o, r
ESTIMATED COST(REQUIRED) Date: �� /l3
•Fair market value of all labor and materials foundation to finish
Initials:
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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#: BLD13-00351 Received Date 11/6/2013
SITE ADDRESS: 191 FOUR CORNERS RD Issue Date 11/6/2013
PORT TOWNSEND, 98368
APPLICANT: COLEEN CAMERON PHONE: 360-385-3730
191 4 CORNERS RD
PORT TOWNSEND WA 983689367
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001333026 Section: 33 Township: 30N Range: 01W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2014
OWNER, COLEEN CAMERON PHONE: 360-385-3730
if different: 191 4 CORNERS RD
PORT TOWNSEND WA 983689367
PROJECT DESCRIPTION: SWAP OUT OF 250 GAL 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 11/6/2014.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:
FinalApproval: 11 25- -t 7
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 BLD_Permit_Propane.rpt 11/6/2013