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HomeMy WebLinkAboutBLD2013-00021 • BUILDING PERMIT APPLI ION B Review Type: Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD13-00021 Received Date: 1/22/2013 SITE ADDRESS: 2340 E MARROWSTONE RD NORDLAND, 98358 OWNER: ELLEN B LERICH PHONE: 2340 E MARROWSTONE RD NORDLAND WA 98358-9522 R NORDBY SHORT PLAT SUBDIVISION: Block: Lot: 4 PARCEL NUMBER: 976200706 Section: 33 Township: 30 N Range: 01 E CONTRACTOR: TOLLEFSON BUILDERS INC PHONE: (360) 732-4080 TODD HULBERT PO BOX 100 CHIMACUM WA 98325 Contractor's License TOLLEBI977N9 Expires 3/16/2013 REPRESENTATIVE: TOLLEFSON BUILDERS INC PHONE: (360) 732-4080 TODD HULBERT PO BOX 100 PROJECT DESCRIPTION KITCHEN REMODEL TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP ALT MAIN: VALUATION 45,000.00 ADD'L: HEAT TYPE: 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: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Tonal. Routing Date Type Amount Paid By: Date: Receipt: Approved/Date Permit $593.25 LYK 01/22/13 139917 Plan Check $385.61 LYK 01/22/13 139917 APPROVED State Building Code $4.50 LYK 01/22/13 139917 Total: $983.36 JAN 23 2013 Jefferson County DCD \\firlcmor4\r7o4o\fnrme\F PI fl Ann PIA rn+ 1/77/7(111 CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX(360)379-4451 Carl Smith, Director/Building Official PERMIT#: BLD13-00021 SITE ADDRESS: 2340 E MARROWSTONE RD Issue Date: 01/23/2013 NORDLAND, 98358 Final Date: 10/16/2013 APPLICANT: ELLEN B LERICH PHONE: 2340 E MARROWSTONE RD NORDLAND WA 98358-9522 SUBDIVISION: R NORDBY SHORT PLAT Block: Lot: 4 PARCEL NUMBER: 976200706 Section: 33 Township: 30 N Range: 01 E PROJECT DESCRIPTION: KITCHEN REMODEL THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2009 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 10/16/2013 \\tidemark\data\forms\F_BLD_Occupancy.rpt 10/28/2013 • r‘iikv6,`r'ON c JEFFERS§COUNTY `ea DEPARTMENT OF COMMUNITY DEVELOPMENT 1. iq 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax 14t1N0 www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Mc } Pro' ct Description(i I e separate sheets as necessary): 1. ►'¢fl O A Tax Parcel Number: '76 Z 0c'7Oe. Property Size: /I3 ,q-c . (acres/square feet) Site Address and/or Directions to Property: / Z `(� 0 E, MrTi nobo oA) 6 RP. /V©PLr1, Property Owner(s)of Record: cLL&/ T. t ,ZS22/G67 Telephone: Fax: email: Mailing Address: Applicant/Agent(if different from owner): -7-5 DO 7o L(l /.r©-✓ Telephone: Fax: - 1. Mailing Address: , 1 ,, , l What kind of Permit?(Check each box that applies ❑Lot or Road Segre• ❑Building ❑Critical Areas Stew gship PlaiA N 2 2 20�3 1 ❑ Demolition Permit ❑Variance(Minor, M:j•r r:Reasonable Economic Use)J; ❑Single Family ❑Garage Attached/Detached ❑Conditional Use[Ciao,G C .or Cl** L___, ❑ Manufactured Home .❑ Modular . - ❑ Discretionary"D"o, Unnamed kaft' t siflCatllbn , I ❑ Commercial* ❑Special Use(Essential Pubt (Fa Iliti*Ifi*DE_'F'nr,M J!Y___, ❑ Change of Use ❑Boundary Line Adjustment ❑ Address ❑ Road Approach_ ❑Short Plat** ❑ 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/ O2 /6, Z ©# to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE cEI9 lA(ti '! Date: z z /3 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 appli • 'T --h-,wants prior notice. / Signature: �.� , —' —��' � Date: 'z / 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-transfera a responsibili f r adherin to and complying with the ESA. The Applicant has read this disclaimer a d signs and dates it below. � / Date: /disclaimer -=- / 3 Signature: /JJ . .. , .,a u..r...�•nlauu r�rr�non•rM�----_,',or T ... _\TA n..Y...A....t:...,. ..S )O(14 a.... • • 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 protect. Signature: Date: _ \ RAI CONTRACTOR O NUFACTURED HOME INSTALLER: PHONE: FAX: 1 Ot \12 , 16/5 ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTORS LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: I EMAIL Project Type: F me Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New (Wood Existing: i/ 0 Sewer ❑ Addition 0 Steel Proposed: 1 ri Bank 0 Community System Sc_A,Iteration/Remodel 0 Concrete Total: 12 Height: ❑ Individual System ❑ Repair 0 Masonry SEP Permit# O Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type_of Heat: Proposed: ❑ Public E. C— 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 tems below that apply: 1 Underground Tank 1 Above ground Tank Size of Propene Tank: 1 Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 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 rvForlOffiice Use`Only, 4mount Revision Main Floor Heated EH BId App Review: 2nd Floor Heated Consiste'Icy Review: Other Heated Base fee Mezzanine Addition I Section: Heated Basement Plan Chick fee: 325 . CI Unheated Basement State Strcharge fee: S° Other Unheated Pot Water Review fee: ________.--, Garage/Carport SUBTOTAL Decks 911/Rd pproach fee: �- Other TOTAL: l`I s3 . 5ce Receip Number: I ^Jq q I' Cash/C eck Number: ,, �� TIMATED COST(REQUIRED) Date: �� 'Fair - - _ oundation to finish �. ..� c—/�/0�v Initials: Contractors or Tradespeoplointer Friendly Page Page 1 of 2 General/Specialty Contractor A business registered as a construction contractor with LEI 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 TOLLEFSON BUILDERS INC UBI No. 601222162 Phone 3607324080 Status Active Address Po Box 100 License No. TOLLEBI977N9 Suite/Apt. License Type Construction Contractor City Chimacum Effective Date 8/29/2003 State WA Expiration Date 3/16/2013 Zip 98325 Suspend Date County Jefferson Specialty 1 General Business Type Corporation Specialty 2 Unused Parent Company Other Associated Licenses Specialty Specialty Effective Expiration License Name Type Status 1 2 Date Date TOLLSCI107D6 TOLLSHARK Construction General Unused 3/26/1990 3/15/2005 Archived CONSTRUCTION CTION INC Contractor TOLLSHARK Construction TOLLSCC217NOCNST/CUSTOM Contractor General Unused 8/20/1979 8/20/1990 Archived WOODWORK Business Owner Information Name Role Effective Date Expiration Date TOLLEFSON, RICK F President 08/29/2003 MAYSHARK, HOLLY H Secretary 08/29/2003 Bond Information Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date TRAVELERS CAS& 5 206085510 03/15/2002 Until Cancelled $12,000.0001/25/2002 SURETY 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 18 Houston TEN-11142 05/15/2012 05/15/2013 $1,000,000.00 05/15/2012 Specialty Ins Co Contractors 17 Bonding& C11SJ6295 05/15/2012 05/15/2013 05/15/2012 $1,000,000.00 05/09/2012 Insuranc American 16 Safety 10TSRGL37620005/15/2011 05/15/2012 $1,000,000.0005/12/2011 Indemnity Co AMERICAN 15 SAFETY 10TSRGL30730005/15/2010 05/15/2011 $1,000,000.0005/14/2010 INDEMNITY CO AMERICAN 14 SAFETY 10TSRGL23670005/15/2009 05/15/2010 $1,000,000.0005/14/2009 INDEMNITY CO AMERICAN 10TSR-GL1161- 13 SAFETY 00 05/15/2008 05/15/2009 $1,000,000.0005/14/2008 INDEMNITY CO https://fortress.wa.gov/lni/bbip/Print.aspx 1/22/2013 Contractors or Tradespeoplointer Friendly Page Page 2 of 2 AMERICAN 10TSRGL1161- 12 SAFETY 00 05/15/2007 05/15/2008 $1,000,000.00 05/16/2007 INDEMNITY CO AMERICAN 11 SAFETY 10TSRGL 05/15/2007 05/15/2008 $1,000,000.00 05/14/2007 INDEMNITY CO AMERICAN 10 SAFETY 10TSRGL06730005/15/2006 05/15/2007 $1,000,000.0006/13/2006 INDEMNITY CO AMERICAN 9 SAFETY TSR021100398 05/15/2006 05/15/2007 $1,000,000.00 05/11/2006 INDEMNITY CO 8 U S F INS CO TSR105610 05/15/2006 05/15/2007 $1,000,000.0002/22/2006 Summons/Complaint Information No unsatisfied complaints on file within prior 6 year period Warrant Information No unsatisfied warrants on file within prior 6 year period Infractions/Citations Information No records found for the previous 6 year period https://fortress.wa.gov/lni/bbip/Print.aspx 1/22/2013 r/// ill II\ •.,,k1 ' .,,, ,,, ,, ) LI ,.._,„ .......... r c> 6 6 at / ■.................. 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