The URL can be used to link to this page

Home My WebLink AboutBLD2006-00501 • • 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 b -.assumin ,,, res..l ibility of the General Contractor for the proposed project. Signature:`` Y�'P Date: -7Lf/2�' GENERAL CONTRAC C OR MANUFACTURED HOME INSTALLER: PHONE: FAX: -7JF�r f w - 5 ,,J -De-A- ��Af -Dc �� c 3 ) was- (z.Ls ( ) e- MAILING ADDRESS: \)f t 5�'J( LA ��r Prr EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: f t_ /c16•- 1 & 1 NUMBER ARCHITECT/ENGINEER: L j�a� 6-�� PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: X New K Wood Existing: ED ❑ Sewer ❑ Addition ❑ Steel Proposed: 2 :ank eight: ,;:Community System ❑ Alteration/Remodel ❑ Concrete Total: v ` Individual System ❑ Repair ❑ Masonry SEP Permit# Oft f)-7 ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: v Set aac : [7 Private well ❑ Two Party Type of He t: Proposed: '� yp 1K Public j,7_=c=r ,C,,, Total: 2- Name f S'ss�teem: C . If this is a Commercial Project you must answer the following y- / (1) Number of Parking Spaces: Current: Proposed: Nu ber of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Curren 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: [1 Underground Tank X Above ground Tank Size of Propane Tank: I 56 (-et Ai Heat Stove b`f Cook Stove ❑ Woodstove ❑ Fireplace Insert K Hot Water Tanis ❑ Pellet Stove ❑ 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,.J; ,� , 3'.,. r fr a , -1 a' rt- , Main Floor Heated g321 q,Ctj EH Bid App Review: t51� d 1i _ Cos 2"°Floor Heated - Consistency Review: Other Heated Da 10-•i gq Base fee: Mezzanine Additional Section: --- Heated Basementdiv -? . Plan Check fee: (� Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: q0 .‘° Garage/Carport ��•.f j�. .:;;.11 I A#S wt SUBTOTAL 'L 473 i s i t -3% al- i . iq Decks 1-'20 ;l0C(o.gC,� Approach fee: _ t t vats: ` tA) Other TOTAL: $4Q IC\ Receipt Number: 4 - Cash/Check Number: ESTIMATED COST(REQUIRED) lar.:?' : Date: •Fair market value of all ran m ' s foundation to finiih�7e?, 2 - Initials: (illY/ 50 00o Ofzfa...„ G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc .3.SON L, y c ..a i �w {, JEFFER N COUNTY I 41../ g DEPARTMENT OF COMMUNITY DEVELOPMENT 1111 `4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 •• 360/379-4451 Fax ,qS, NO&O/ www.co.jefferson.wa.us/commdevelopment t ,.-: r Master Permit Application MLA: .1 U'O 1W Project Description(include separate sheets as necessary): /J S/A/6----e-- 6111/7 i 06.-ic. I r el—mi�-0 c Av1/4-19 Property i- t (),-A ._ext.(N" rJ�'jc t Tax Parcel Number: / - S-:;,_. -;�`.-; Size: 16)57)0 (acres quare feety, Site Address and/or Directions to Property: rtiv i„(-- k-; PGa,-er-.--C 7-Ce—6i 1-1--11C'5 ) Property Owner(s)of Record: TC'ZR/ / (4't Srt 5-7 E4 J Telephone: �� >v—.�� " — (24=5 Fax: 5'� email: / - ( 5-f c t el�yimf J A Mailing Address: Ot( (- jam, -S v�r f 1 T J O u-Ok- I Applicant/Agent(if different from owner): Telephone: .o � v(Lv Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) "Building ❑Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]** f Single Famil 0 Discretionary"D"or Unnamed Use Classification ga Garage ttached Detached ❑ Special Use(Essential Public Facilities)** 79 Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** Ll Change of Use ❑ Long Plat** Address Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** Propane ❑ Plat Vacation/Alteration** ti Allowed "Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions'`'` ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference **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 .5773 f' to act as my agent in matters relating to his a plication for permit(s). OWNER SIGNATURE '� `, ." Date: •7 '� J 6 J By signing this application form,t ner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's 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.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Date: 0 The action or actin pplicant 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- transferabl ibility for adherin t an corn • ' . The Applicant has read this disclaimer and s' ns an dates it below. Signature: �u Date: i 2� Ej‘, G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc