HomeMy WebLinkAboutBLD2013-00352 UILDING PERMIT APPLICA N BLDI3-00352
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD13-00352 Received Date: 11/6/2013
SITE ADDRESS: 151 GIBBS LAKE RD
CHIMACUM, 98325
OWNER: DANNY D OSMER PHONE:
DEANNA R OSMER
PO BOX 232
CHIMACUM WA 983250232 LOWELL DAY SHORT PLAT#B
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901342018 Section: 34 Township: 29 N Range: 01 W
CONTRACTOR: FRANSON TRUCKING AND EXCAVATING PHONE: 360-821-9262
430 NO NAME RD
PORT LUDLOW WA 98365
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP DEMO OF SINGLE WIDE MOBILE HOME
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP DEM 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: OSS
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $76.00 MEB 11/06/13 145531 APPROVED
OVED
Total: $76.00 NOV 0 6 2013
Jefferson County DCD
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#''' °11 c `J 1 . JEFFERSON COUNTY
' 4 DEPARTMENT OF COMMUNITY DEVELOPMENT
f' ''� 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
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q pN- www.co.jefferson.wa.us/commdevelopment
"Yhr1/1W.
Master Permit Application MLA:
'Project Description(include separate sheets as necessary):
14o)S4— 1jco ISt\••t p. 4..i Aof •
•
Tax Parcel Number: 1 d 1I,L.4-2..O i 8 Property Size: g-i- (poQ ma FT (acres/square feet)
Site Address and/or Directions to Property:
51 (51^FI>6S 1—(A kg CLa(AL r t-4>rtoca(IvrA- u3A QEj3ZS
Property Owner(s)of Record: DAt) - 1\CAN x-. 4.)1=k OSrv&.F.g_
Telephone: 7R((D 1.12 Coal Fax: -/ email: .�
Mailing Address: Qb Sox. 232 Lvrronq(_,), Wt\ q2>3lc
Applicant/Agent(if different from owner): FQAt.s..bt. 1-4..c ti x-i -k Q.0..c ko s,,vrCJ(n
Telephone: 2(00 - t)7 1 - c(1(02 Fax: email: _
Mailing Address: - LiSo (Jo f3'f)iMC'.. Qo X 1—...)1)i—ov.1 uX 11cA(4)..C-
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation
❑Building ❑Critical Areas Stewardshi i ��- E
x Demolition Permit ❑Variance(Minor,Major or :ti, .1'0_61
�
❑ Single Family ❑Garage Attached/Detached ❑Conditional Use[C(a),C(. *,
❑ Manufactured Home .❑ Modular - ❑ Discretionary"D"or Unna _ e Classification
❑ Commercial* ❑ Special Use(Essential Pu d r : ilitietiM 6 2 3i3
• Change of Use ❑ Boundary Line Adjustment i
❑ Address ❑Road Approach_ ❑Short Plat**
o Home Business ❑Cottage Industry ❑Binding Site Plan** JEFFERSON COUNTY
❑ Propane ❑Long Plat** t,i�i NITY D1�IElOPMENT
• ❑Sign -• ❑ Planned Rural Residential . endments**
❑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/ lb.(' '_..441 (Z. • .)_._1ai• to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE ,�Mill '�=. �i- Date: € T 4 ( 13
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 inspection •to 's access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the application that,- • she w- .rio, •-
Signature: Date: Se-P c Z • V3
The action or actions Applicant will un Y ertake 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
i_
"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• are in co nce ith the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf able spons • for dhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date: SCOT- Z , CS ,
40 •
,
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:
�
2At• 0—\--e.11,I.c.- A-St•N -k Py..vA`C' (36d &LA c(Z(o2 ( )
MAILING ADDRESS: 43b P()(vWrtic._ Q e2C't---l0 > EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: �'2( l•- —r'Ea4CS QOM NUMBER
ARCHITECT/ENGINEER: p,J PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition 0 Steel Proposed: Bank 0 Community System
❑ Alteration/Remodel 0 Concrete Total: _ Height: 0 Individual System
❑ Repair ❑ Masonry SEP Permit U
❑ 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 f No
If this is a Pro•ane Tank and/or A••liance Installation •ermit mark all items below that a••I :
t Underground Tank t Above ground Tank Size of Propane Tank:
1 Heat Stove i Cook Stove 1 Woodstove ► Fireplace Insert 1 Hot Water Tank l Pellet Stove t Other
Is this appliance being installed in a Manufactured I 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 BId 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: III 5--3)
Cash/Check Number: n v 3_/.
ESTIMATED COST(REQUIRED) Date: \l � '2
•Fair market value of all labor and materials foundation to finish �J
Initials: ,O
• •
215 SW 153rd Street Burien,WA 98166
OFFICE: (206)988-1746 FAX:(206)988-1978
[K 0 Z T H E Z N NVLAP Lab Code:200511-0
■NcoUSTHIAL NYti�ENE, ANC.
Bulk Asbestos Analysis Report
Northwest Asbestos Consultants NIH Batch Number: 13-00548
406 Reed Street Client Job Number:
Port Townsend,WA 98368- Turn Around Time: 3 Day C
Project Location: 151 Gibbs Lake Rd., Chimacum, WA Samples Analyzed: 3
Client Sample Number: 1 Lab Sample Number:13-00548.0001
Client Sample Description: Caulking Roofing Material-Silver/White
Client Sample Location: Not Given
Sample Comments: Materials distinguishable but inseparable Checked If Sample Not Analyzed 0
White,tan and black flexible material
Asbestos Fibrous Components: Non-Asbestos Fibrous Components: Non-Fibrous Components:
3%. Chrysolite Asbestos 5% Cellulose 30% Asphalt Filler and Binder
62% Filler and Binder
Client Sample Number: 2 Lab Sample Number:13-00548.0002
Client Sample Description: Vinyl Flooring-Orange!Gold
Client Sample Location: Kitchen Area
Sample Comments: Materials distinguishable but inseparable Checked If Sample Not Analyzed 0
Red,Brown and black vinyl with off-white fibrous backing
Asbestos Fibrous Components: Non-Asbestos Fibrous Components: Non-Fibrous Components:
15% Chrysotile Asbestos 40% Filler and Binder
45% Vinyl Filler and Binder
Client Sample Number: 3 Lab Sample Number:13-00548.0003
Client Sample Description: Ceiling Material
Client Sample Location: Homogenous
Sample Comments: Materials distinguishable but inseparable Checked If Sample Not Analyzed ❑
White paint on light brown compressed fiberous material
Asbestos Fibrous Components: Non-Asbestos Fibrous Components: Non-Fibrous Components:
No Asbestos Detected 85% Cellulose 10% Paint
5% Filler and Binder
pEOEIIVED
I
NOV 6 2013
JEFFERSON COUNTY
DEPT.OF COMMUNITY DEVELOPMENT
Sampled by: Bob Witheridge 9/4/2013 L� ---�^-- �
Received by: Fermin Uribe 9/5/2013
Reviewed by Jude Cummings 9/8/2013
Jude Cummings,Laboratory Manager
Page 1
. •
SSURED Invoice
U
Lrry ENVIRONNENTAL INC. General Contractors Specializing in Asbestos/Lead
2702 "A" St. • Tacoma, WA 98402 Removal, Interior Demolition and Mold Remediation
Tacoma (253)572-7175 Seattle (206) 763-7177 Port Orchard (360) 769-7175 Fax (253) 779-4020
Date Invoice#
• 1 0/28/2013 7764
Bill To 1 Job Name
Derek Franson 151 Gibbs Lake Rd
Chimacum,WA
Ship Via
4.
Email
a#v
474: Q. Rep
Due on Receipt
rr M Rate Amount
Description
Removal and Disposal of 90SF of Sheet Vinyl and 840SF of 3 1,725.00 1,725.00T
Roofing as per scope of work Agin - `
Sales Tax . 9.00% 155.25
'`412:,44r.
.. z z;-;,,
It is a pleasure doing business with you.
Total 51,880.25
Balance Due 51,880.25
• •
SSURED
UALITY ENVIRONMENTAL INC. General Contractors Specializing in Asbestos/Lead
2702 "A" St. • Tacoma, WA 98402 Removal, interior Demolition and Mold Remediation
Tacoma (253) 572-7175 Seattle (206) 763-7177 Port Orchard (360) 769-7175 Fax (253) 779-4020
September 17"2013
Derek Franson
Franson Trucking and Excavating
430 No Name Road
Port Ludlow,WA 98365
Job Site: E C N -
151 Gibbs Lake Rd V I ',
Chimacum,WA 98325
i, ei NOV 6
Re: Asbestos Abatement Quotation i l
1
Location listed above. 1J
JEFFERSON COUNTY
Derek: DEPT.OF COMMUNITY DEVELOPMENT
Assured Quality Environmental appreciates this opportunity to provide you with this proposal for Asbestos
disposal services. We look forward to corking with you,and hope that out proposal meets your
requirements.
ONE THOUSAND SEVEN HUNDRED TWENTY FIVE DOLLARS ($1,725.00) +Tax
SCOPE OF WORK:
1) Remove Approximately 90 SF of Sheet Vinyl Located in Bath Room and Kitchen.
2) Remove Approximately 840SF of Silver Coated Roofing.
CONDITIONS:
1) Price is based on G.C. Providing Excavator.
2) Price includes Asbestos Liability Insurance for Two Million ($2,000,000) Dollars.
3) Price includes Disposal of ACM only.
4) All work will be strictly performed per EPA,WISHA& OSHA Standards.
5) Price is based on Power and Water being provided by the Owner. ---
6) Price is based on all items removed from the area of abatement prior to our
mobilization.
7) Price includes permits.
8) Price includes air monitoring by AQE, Inc.
9) TERMS:PAYMENT IN FULL UPON COMPLETION OF WORK; 1.5%
Interest charge due on unpaid balance.
NOV/06/2013/WED 10: 50 AM ORCAA FAX No. 360491611U P. 001/001
Sep 23 13 07:29a Derek & Amy son 332-6899 p.1
•
16113A 3 ,.. Olympic Region Clean Air Ag=cy
tic -red 3940-B Limited Lane NW .
,t& /.../ c Olympia,WA 98502
eii` '360-1 535-7610.FAX!360' 491-6308 ,
,.'..� "`.. ■Fart`Angeles office(360) i�-� 6 Demolition Permit
O R.CA A -�
rs Raymond Office i3G0;942-2137
y4k*, 0!..14:7-1 wan-ORCAA.org
."'f -�.
N, Owner occupied residential dwelling Permit fee:$35.00—Prior Notice-Nonrefundable
[ 1 Other Structures—Permit fee:$60.00—10 working day wait period-Nonrefundable
PROPERTY OWNER
Name; Phone: 314 '}IL co'tatl Email: '.-.' .
A, N r C)C+M E.,.CQ FAX r ) Mobile:( "
Ilanitn 3.ddmess: City: State: Zn
Site Address: City. State: Zip:
S t y. L _9_.- __— h. _ -- • G}{ 'yW:4(t)Yy. , t•- irS3.--tj
DEMOLITION CONTRACTOR[ 1 Cheek if same AS p,taperty owner information _
Business N lame: 13l)oile: .3W X21 • .6.7„ Erra1:
Q.L,.:.s* ( O CA _ ;.�: FAX t y,. 4
Onnsite Contact: . Phce e: ACA) ell Wog— Niobilrr:r' `
Mailing Address: . City: State: Zip: `
L F b d 'L4yul9C. II�T t ca.a t r °I731.
DEMOLITION INFORMATION __ _ _ — - • f
#of Structures being demolished: Start Date: z i Completion Dabc:1 1
I °C r I' , 15 j CAL-' ° t
•• Asbestos present , Yes _No Survey attached Tree No Has all identified asbestos been
__ removed _Yes ...XNo
Pts.st7a- C,.-* .fit- ' .0.a.t., 42.7.A.tx.>
DEMOLITION PROJECT CATEGORY
t.Complete Demolition
[ ]Training Fire—Fire Agency: -- .
[ ]Renovation,Alteration,Remodeling,Maintenance,or other Construction
[ J Emergency—Additional fits of$50.00(ixtust be accompanied by Government Ordered Decbtration-Commercial only)
I have read and Trill abide by the conditions set forth in this penal"'and a#yaddendtnn thereto. I do hereby certify
that all identified asbestos has been removed and the mfarfnation in this application and supplemental data
described herein is to the-best ofrayimowjledge,accurate and compkrc.
Applicant Name 4 ,Signature � Date
f 35•- -
Date Application Received Payment Info. approved �� ',asbestos Pe rrvt
[ ]Cash Id Dissppi�a Permit 4 ASBOO
RECEIVED [ ]Check: #, Pe
Demolition, emit
xedrt Card uc.) Review date:11/4/13 Pecintit n
SEP232013 •
Receive datc:Lf i3 Reviewed by: ✓
a_, U¢of yy, A eleg Um Daly .4getrry Use Ord Arm!"Use Oaall
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Site Plan Checklist
A Site Plan. All site plans shall be drawn with a straight edge
&features shall be to scale using an engineer scale.
For Residential Applications
A site plan printed on 11 X 17 to scale(if on larger paper please submit 7 copies) Please show the following on all
site plans.
❑ North arrow
❑ Title block with the project name, address, drawing title, tax parcel number, &the name/address/phone of
the person preparing the drawing.
O All Property boundaries, dimensions, total parcel acreage or square footage dimensions.
O Building footprint square footage for all proposed'Cexisting structures[for Site Plan Approval Advance
Determination (SPAAD)applications show buildable area rather than building footprint]
• 0 Environmentally sensitive areas such as ravines, seasonal creeks, bodies of water, wetlands, steep slopes,
etc.
❑ On-site septic system location or sewer lines (existing or proposed) Show measurement from foundation to
septic tank, drainfield, & reserve area. Show transport line.
❑ Well location &water lines. Show 100' radius around well.
❑ Impervious surfaces such as driveways or patios. Show driveways all the way to access road, not just to
the property boundary.
❑ Setback distances from property boundaries to structures, distance between structures, &distances from
structures to environmentally sensitive areas such as wetland, shorelines, steep banks, etc.
O Location of any easements &encumbrances such as utility or access easements.
O Method & location of stormwater disposal facilitates such as drainage swales, tightlines, dry wells, curtain
drains, etc.
❑ For applications on marine or river shorelines show ordinary high water mark, top of banks& heights of
banks.
❑ Locate the Propane Tank, Size of tank, A/G or U/G &distance from nearest bld.
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PROPERTY LINE
___ — — — - — CENTERLINE VIEW STREET
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Date_11.1_3-- time received 1)-- Z.Z-am /C) Mon. 41110 Wed: Thur. -Fri.
ELD: c_3____— ___Z-------
-
OWNER: • • Contact Name
. . L_ K
ADDRESS: - —5=__j ___ _ee,5__._ Contact Number 360
/ L ff . .
. _ 206
3-• •
Notes: - ,
• - .
Foundation Plun___31_ 23in Framing Propane Tank • Mechanical -.
___________--
Setbacks _ Under-ground Framing Under ground Furnace
Footing ____ Rough in Air seal Above ground • Gas _
Stemwall _ k-lydronic Exterior shear Exterior lines Oil
Straps _ interior shear Interior lines • Ducts A
I'
Post Hole Ventilation Appliance
• Underfloor _ Gas/wood stove
Man-Homes
Setbacks ' • Insulation .
Final Inspection
Foundation- - •••:.- ••••
--,i
Block&Tie floor wall ceiling Address Posted
1
-..-
9 •
DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD13-00352 Received Date 11/6/2013
SITE ADDRESS: 151 GIBBS LAKE RD Issue Date 11/6/2013
CHIMACUM, 98325
APPLICANT: DANNY D OSMER PHONE:
DEANNA R OSMER
PO BOX 232
CHIMACUM WA 983250232
SUBDIVISION: LOWELL DAY SHORT PLAT#B Block: Lot:
PARCEL NUMBER: 901342018 Section: 34 Township: 29N Range: 01W
CONTRACTOR: FRANSON TRUCKING AND EXCAVATING PHONE: 360-821-9262
430 NO NAME RD
PORT LUDLOW WA 98365
OWNER, DANNY D OSMER PHONE:
if different: DEANNA R OSMER
PO BOX 232
CHIMACUM WA 983250232
PROJECT DESCRIPTION: DEMO OF SINGLE WIDE MOBILE HOME
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 INSPECTION:
FinalApproval: II -■ Z—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 11/6/2013
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