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Home My WebLink AboutBLD2013-00373 UILDING PERMIT APPLICA 90 N BLDI3-00373 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD13-00373 Received Date: 11/25/2013 SITE ADDRESS: 1612 HASTINGS AVE W PORT TOWNSEND, 98368 OWNER: DALE R WURTSMITH PHONE: 360-385-6379 SANDRA WURTSMITH 1612 HASTINGS AVE W PORT TOWNSEND WA 983689213 SUBDIVISION: Block: Lot: PARCEL NUMBER: 001043003 Section: 4 Township: 30 N Range: 01 W CONTRACTOR: RIGHT CHOICE CHIMNEY SVC PHONE: 10234 YATES LN NW BREMERTON WA 98312 Contractor's License RIGHT*077PM Expires 1/4/2014 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI Wood stove permit 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: Approved/Date Permit $0.00 KKH 11/25/13 Permit $0.00 KKH 11/25/13 APPROVED Total: $0.00 NOV 2 5 2013 Jefferson County DCD \\tidemark\data\forms\F_BLD_App_Bld.rpt 11/25/2013 Contractors or Tradespeople Printer Friendly Page Page 1 of 2 •General/Specialty Contractor A business registered as a construction contractor with Lfxi to perform construction work within the scope of its specialty.A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance. Business and Licensing Information Name RIGHT CHOICE CHIMNEY SRVC,THE UBI No. 601462819 Phone 3607920356 Status Active Address 10234 Yates Ln Nw License No. RIGHT**077PM Suite/Apt. License Type Construction Contractor City Bremerton Effective Date 10/14/1993 State WA Expiration Date 1/4/2014 Zip 98312 Suspend Date County Kitsap Specialty 1 General Business Type Individual Specialty 2 Unused Parent Company P Y Other Associated Licenses License Name Type Specialty 1 Specialty Effective Expiration Status 2 Date Date WWBCI**1010QWWBC INC Construction General Unused 9/18/1990 9/21/1993 Archived Contractor KITSAP Construction KITSAFD169LM FIREPLACE ft Contractor General Unused 6/14/1984 1/18/1988 Archived DECOR INC MAGMAI*1790G MAGMAS INC Construction General Unused 9/7/1983 6/10/1988 Archived Contractor KITSAP Construction KITSAI*214NB FIREPLACE ft Contractor Carpentry/Framing Unused 8/2/1979 3/10/1984 Archived DECOR, INC GOLDSM*231NAGOLDSTIEN, Construction General Unused 8/1/1977 8/1/1981 Archived MOSS Contractor Business Owner Information Name Role Effective Date Expiration Date ORSBORN, DAN C Owner 10/14/1993 Bond Information Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date AMERICAN NATIONAL 5 790286533663 09/22/2001 Until Cancelled $12,000.00 09/28/2001 FIRE INS CO Assignment of Savings Information No records found for the previous 6 year period Insurance Information Insurance Company Name Policy Number Effective Date Expiration Date Cancel Date Impaired Date Amount Received Date MUTUAL OF 10 ENUMCLAW INS NC42684 10/07/2010 Until Cancelled $500,000.00 09/15/2010 CO MUTUAL OF 9 ENUMCLAW INS NC42684 10/07/2009 10/07/2010 $500,000.00 12/23/2009 CO MUTUAL OF 8 ENUMCLAW INS NC42684 10/07/2007 10/07/2009 $500,000.00 10/06/2008 CO Summons/Complaint Information No unsatisfied complaints on file within prior 6 year period https://fortress.wa.gov/lni/bbip/Print.aspx 11/25/2013 Contractors or Tradespeople Printer Friendly Page Page 2 of 2 • Warrant Information No unsatisfied warrants on file within prior 6 year period • Infractions/Citations Information Infraction/Citation Date RCW Code Type Status Violation Amount FWHIJ00323 12/4/2008 43.22.435 RCW FAS INFRACTION Satisfied $200.001 I 1 https://fortress.wa.gov/lni/bbip/Print.aspx 11/25/2013 goN cal, JEFFERSOOOUNTY ` pi DEPARTMENT OF COMMUNITY DEVELOPMENT "' 621 Sheridan Street• Port Townsend •Washington 98368 4 360/379-4450 • 360/379-4451 Fax www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Project Description(include separate sheets as necessary): ttvL Si'-'irl( LI�� lolJ Tax Parcel Number: e2 0\ r'"v?>e '3 Property Size: 5 A,44; (acres/square feet) Site Address and/or Directions to Property: \(o L'a ikvo. , r�w�srr.�p Property Owner(s)of Record: X1\1 - 1Ar.1.6aq \■-■:■■>a-c—c7 -o Telephone: '3$S-G 3-j' Fax: email: b S A ta0,i Q,OL7 4._-..M Mailing Address: %0\41,.4,7-1 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 �„ � v;r ❑Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) ❑Single Family ❑Garage Attached/Detached El Conditional Use[C(a),C(d),or C]** ❑ Manufactured Home .❑ Modular ❑ Discretionary"D"or Unnamed Use Classification ❑ Commercial* ❑Special Use(Essential Public Facilities)** ❑ Change of Use ❑Boundary Line Adjustment ❑ Address ❑ Road Approach ❑Short Plat** ❑ Home Business ❑Cottage Industry ❑Binding Site Plan** ❑ Propane ❑Long Plat** O Sign - - - ❑Planned Rural 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 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 heoLshe wants prior notice. Signature: Date: /OS/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-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature. Date: 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: Date: _ GENERAL `D T2RAC OI ' MANUFACCTUURREDD HOME INSTALL : PHONE: FAX: ��--'` 0( " tom' art.-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 ❑ Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System D Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System C Repair ❑ Masonry — SEP Permit# L 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 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 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 EH Bld App Review: 2°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: Cash/Check Number: ESTIMATED COST(REQUIRED) Date: .Fair market value of all labor and materials foundation to finish L Initials: 1 G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc 0 S 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#: BLD13-00373 Received Date 11/25/2013 SITE ADDRESS: 1612 HASTINGS AVE W Issue Date 11/25/2013 PORT TOWNSEND, 98368 APPLICANT: DALE R WURTSMITH PHONE: 360-385-6379 SANDRA WURTSMITH 1612 HASTINGS AVE W PORT TOWNSEND WA 983689213 SUBDIVISION: Block: Lot: PARCEL NUMBER: 001043003 Section: 4 Township: 30N Range: 01W CONTRACTOR: RIGHT CHOICE CHIMNEY SVC PHONE: 10234 YATES LN NW BREMERTON WA 98312 Contractor's License RIGHT*077PM Expires 1/4/2014 OWNER, DALE R WURTSMITH PHONE: 360-385-6379 if different: SANDRA WURTSMITH 1612 HASTINGS AVE W PORT TOWNSEND WA 983689213 PROJECT DESCRIPTION: Wood stove permit 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 11/25/2014. REQUIRED INSPECTIONS: Tank/Line/Appliance: FinalApproval: I L-14-13 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 11/25/2013