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Home My WebLink AboutBLD2015-00236 - 01 PERMIT APPLICATION BUILDING PERMIT APPLICILBLD15-00236 r1 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00236 Received Date: 7/9/2015 SITE ADDRESS: ---SENTINEL FIRS RD OWNER: ROBERT HUBERT PHONE: 360-379-5454 391 SENTINEL FIRS RD PORT HADLOCK WA 98339-9763 SUBDIVISION: Block: Lot: PARCEL NUMBER: 921193027 Section: 19 Township: 29 N Range: 1E CONTRACTOR: TOWN &COUNTRY POST& FRAME PHONE: 425-743-1555 16521 HWY 99 SUITE C LYNNWOOD WA 98037-3161 Contractor's License TOWNCPF099LT Expires 6/30/2015 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW GARAGE NO PLUMBING - NO HEAT TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 33,292.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: 1,152 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: 0 Prop: Prop: 0 Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $421.00 SRE 07/09/15 156237 ®��D Plan Check $273.65 SRE 07/09/15 156237 ACIPR State Building Code $4.50 SRE 07/09/15 156237 �" Total: $699.15 JUL 2' 2015 J€fterson County DCO llflrinm nr4\rlofn\fnrmc\F RI Il Ann Rlrl rnk 710/9(11F MILDING PERMIT APPLICATIR BLD15-00236 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00236 Received Date: 7/9/2015 SITE ADDRESS: ---SENTINEL FIRS RD OWNER: ROBERT HUBERT PHONE: 360-379-5454 391 SENTINEL FIRS RD PORT HADLOCK WA 98339-9763 SUBDIVISION: Block: Lot: PARCEL NUMBER: 921193027 Section: 19 Township: 29 N Range: 1E CONTRACTOR: TOWN &COUNTRY POST & FRAME PHONE: 425-743-1555 16521 HWY 99 SUITE C LYNNWOOD WA 98037-3161 Contractor's License TOWNCPF099LT Expires 6/30/2015 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI\ NEW GARAGE NO PLUMBING - NO HEAT TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 33,292.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: SHORELINE: GARAGE: 1,152 CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: 0 Prop: Prop: 0 Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $421.00 SRE 07/09/15 156237 Plan Check $273.65 SRE 07/09/15 156237 State Building Code $4.50 SRE 07/09/15 156237 Total: $699.15 1\firlcm rklrta\fnrrnc\P RI Il Ann Rlrl rnt 7/0/9f 1c Parcel Details • . Page 1 of 2 '[- ' r- J f 1,,,,i ,, - ,-.„......' ::_3 .,."+IraS. _ _ W' + „..,,,„.„„ ,;. ,,..i .i ,. .r ` M :ii .' Home County Info :.Departments Search Parcel Number: 1921193026 SEARCH Parcel Number: 921193026 Printer Friendly Owner Mailing Address: ROBERT HUBERT 391 SENTINEL FIRS RD PORT HADLOCK WA98339-9763 Site Address: 391 SENTINEL FIRS RD PORT HADLOCK 98339 Section: 19 School District:Chimacum (49) Qtr Section: SW1/4 Fire Dist: Chimacum (1) Township: 29N Tax Status: Taxable Range: 1E Tax Code: 0211 Planning area:Tri-Area (4) Sewer: Drainage: Bank: View 1: View 2: Zoning 1: RR-5 - Rural Residential Zoning 2: Zoning 3: Sub Division: Assessor's Land Use Code: 1100 - Residential - Single Unit Property Description: S19 T29 R1E TAX 45 SUBJ/REST COVT #534411 l Tax, A/V, Sales, Photos, and Permit Data Bldg Data Ma Parcel lats&Surveys l Septic Monitoring Info ,,iii'€-;-_; Jefferson county HOME I COUNTY INFO I DEPARTMENTS I SEARCH r'x- Best viewed with Microsoft Internet Explorer 6.0 or later ilSWindows- Mac http://www.co.jefferson.wa.us/assessors/parcel/parceldetail.asp?value=921193026 7/13/2015 Parcel Details Page 1 of 2 !! J ` , f 1 t k a . i exit ,, ,4 11� � jv,1 Home County info Departments Search Parcel Number: 921193027 SEARCH Parcel Number: 921193027 Printer Friendly Owner Mailing Address: ROBERT HUBERT .iktir,t, O Gil., (t i t[-1-. COnUen -k- 391 SENTINEL FIRS RD PORT HADLOCK WA98339-9763 C01-.b'^u''11) Varq2,1, —ic 5 _021, Site Address: V C)124 t — I ' 3. —o . ' k € - (x� h'tm QF 3,I Sent) l ArS WCeSS -h act f 1ro,,�L. Section: 19 School District: Chimacum (49) l� Qtr Section: SW1/4 Fire Dist: Chimacum (1) e)`ict UekIL Township: 29N Tax Status: Taxable Range: 1E Tax Code: 0211 Planning area:Tri-Area (4) Sewer: Drainage: 1 Bank: View 1: wk-• CONA- View 2: Zoning 1: RR-5 - Rural Residential Zoning 2: Zoning 3: Lk 1 k Sub Division: Assessor's Land Use Code: 9100 - Vacant Land Property Description: S19 T29 R1E TAX 138 Tax, A/V, Sales, Photos,and I PPermit Data Bldg Data Map Parcel fats &Surveys ' I Septic Monitoring Info . .-`.•47.;:-.,.r1 , Sellerson County „ HOME I COUNTY INFO I DEPARTMENTS I SEARCH fl Best viewed with Microsoft Internet Explorer 6.0 or later Windows - Mac http://www.co.jefferson.wa.us/assessors/parcellparceldetail.asp?value=921193027 7/13/2015 • • Sally Ellis From: Steve Triplet<permits@permabilt.com> Sent: Friday, July 10, 2015 9:06 AM To: Sally Ellis; Jodi Adams Subject: Hubert Sally/Jodi, I mailed the check for the address review last night but the owner is going in to your offices this morning to discuss this. The owner said that the county made him keep one address for the two lots because the smaller lot could not support a septic system. Steve Triplett Permit Coordinator Permabilt Industries Inc. Celebrating our 42nd Year! 'C intra qt Town &Country Post Frame Buildings 16521 Hwy 99,Ste. C Lynnwood,WA. 98037 425-743-1555 permits@permabilt.com On l ( D 0-e_c_\( LS \ b 'i'd v NS end I�c�c k -1 S-}-toe. acce ) 11 Tur (Judi Lot -- lrOt i Ski ` c v 1.0.e wa,96, _ Gv 4*__1 1 1 r• C . ��oN c06� r DEPARTMENT OF COMMUNITY DEVELOPMENT r's621 Sheridan Street,Port Townsend,WA 98368 , Tel:360.379.4450 I Fax:360.379.4451 � Web:www.co.Jefferson.wa.us/communitydevelopment ��S �O� E-ma l:dcd@co.jeffetson.wa.us �j Nr�l LLLIII v i PERMIT APPLICATION U L( JUL — 9 2015 COM Steps in the Permit Process: p �F1RSpNCoUN -Review application checklist to ensure all information is completed prior to submitting application. h4UNiryDF ly W �ftOPM -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# Site Information -i�7 Assessor Tax Parcel Number: y ' 2.1/ q3 o!� i Site Address and/or Directions to Property: s -J ik 3/I (1 {iffrk-,4 1t QoZrdd kULesGk_ w A— 'j 379 Access(name of street(s)) from which access will be gained: yp F Present use of property: V Description of Work(include proposed uses): ()VT' f .1,4 i F 6 01Z-4—GC • Wastewater-Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: Community Septic Name of System: Case#: Are other residences connected to the septic system? j,JO Additions or repairs to sewage system: Is it a complete or partial system installation: Complete A _ Partial Has a reserve drainfield been designated? ulvkr ll Yes _ No Date of Last Operations& Maintenance check: 14PriL Zo I r Attach last report to application Describe or attach any drainfield easements,covenants or notices on title,which may impact the property: The authorized agent/representative is the mary contact for all project-related questions correspondence. The County will mail /e-mail requests and information about the application to the authorized agent/representative and will copy(cc)the owner noted below. The authorized agent/representative is responsible for communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email(i.e., County email is not blocked or sent to"junk mail"). Applicant/Property Owner Information Property O ner: (� 1-tui- Name: oo-t1^ Ji t r Address: 7/ cn-1. h t" I E('>^s p Poi-i- cccv ivc J< wlik ? i-3 3 J Phone#: _ 3(00-3-79 --Sysy E-mail Address: r4a(z 114.110r4 (offpl,yneiJ. c..Oin _ _ Please co act Authorized Aggentt/ . `Representative with project info. (select only one� Property Owner Signature: ,1' / Date:._57,p. //'-S Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(If other than owner) Name: -in vvN d- (-4 t)/✓TY. Address: (/ ?..-)I d-l(.vl/ q9 cm. G /INA)WO347 WA- 10077 Phone#: kia> '$Z4/ RS'STL• E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO /t• YES Engineer Architect Surveyor /Contractor Consultant Name: A/4 Cnu/vTie'_y -- S-1W(2,174"e -A)®SS License#C� tin/ o 9 q L-T Address: , ,z;-z/ ,441,y Q 7,. S/E C` L.yr✓ni/uoe,r. 6i(/. 6O 37 Phone#: / 7 3. As-5-5- � ? 7 E-mail Address: 4/ -E�&,,�j 4 ';/ ZS-- .CO.-,-,_ Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect _ Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? s Engineer Architect Surveyor Contractor ; , V Name: License# i Address: ) JUL - 9 2015 6' LI L Phone#: E-mail Address: L JEFFFReO tCOUNTY L_ DEPT OF COMMUNITY DEVELOPMENT 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 or her 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I 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. Applicant may request notice ghee uunnty�'s�in ent to enter upon the property for vis• related /to/this application/ and subsequent permit issuance. Signature: � �" G'J®� Print Name2,/'elD //aZi-e/'/4-"" Date: 21J /5". 4n 0 S 1 ,_,ON -. DEPARTMENT OF COMMUNITY DEVELOPMENT ��4 ,p 621 Sheridan Street Port Townsend WA 98368 4C �� Tel:360.379.4450 l Fax:360.379.4451 iti ,-C Web:www.co,Jefferson.wa.us/communitydevelopment 10-2zoz(4 , E-mail:ded@co.jeffecson.wa.us u f,e, -Ts,/N OHO SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PE I JO/ 9 20 f [Tr) Department Use nlReceipj I, Il f Related Application#s: Pa mer{ .• '''''.,',1',P7,,:t �- pp � Y u of e information ;„il i Wli, iii iIi I7ir>., i i i i i, _ Owner Name: � UBtT Assessor Tax Parcel#: 92/ 7 Type of Build : i„iIhO, I: .. New DC. Replacement Relocated Addition Repair Demolition * •A separate permit is required Select One: Single Family Residence Modular Other 6,, 447 - list Proposed Building/Project - , , 11 Number of floors / H new bedrooms existing total bed H new bathrooms existing total bath ,� ,T, ri,Hii 1':' ;',; i, d 41 ,Sty, ., 5 �' I le i 1 0, ii �li ,i �•�i) S . v .1 ry i A , Iil , H� t$oltlCE �5' � i6r�l�i� hk, ' wo I � m ,,,�t i,i ”" Select all that apply: Electric Heating Oil Wood Propane Enter the square foota:e(sq/ft)that a.plies in each field: -,7-7-_ ,,,,,,,,7-'" '' Structure t.. . R a1 Proposed Residential/Commercial Main Floor Residential/Commercial Second Floor Additional Floors-heated/unheated Basement-unfinished Basement-finished space or habitable Detached Garage-heated( t )ed //L-->'Z I Attached Garage-heated/unheated I Garage 2nd fl-unfinished storage Garage 2nd fl-finished space or habitable _ Carport-2 walls or less Deck-uncovered Covered porch Other(shed, barn, pole bldg,etc.) Estimated Cost of Project(Required): $ Supplemental SFR 1 • • Listexistingbuildings on property(i.e.yhouse,garage, accessorydwelling unit,shed, barn, mobile home,other): F�E,St$t ,04 s! � ' " h4T �PPOIi �� @ (SFr -yJ �781 � , »u . �� nidi. . � �,,, d d r oxie 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applic federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson ounty and its employees, representatives or agents for the sole purpose of application review and any require later inspections. pplicant may request notice of the County's intent to enter upon the property for visits rel. -d to this applicat land subsequent permit issuance. Signature: - ,.i 4:04.....v Print Name: 5-7-ei/c (-e,i 7—r Date:• -wi Estimated Cost of Project $ Building Base Fees Building Base Plan Check Review Land Use Review $228.00 Septic Review + $79.00 Potable Water a V u $107.00 Technology/Scan 1 $19.00 J JUL - 9 2015 ENT State Fee $4.50 Other Fees JRSN COUNTYDp DEPT.OF COMFFEMUONfryDVE( ff Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt# Date: Cash/Check/CC: Supplemental SFR 2 ''4. 16521 16521 Highway 99, Suite C C. Lynnwood,WA 98037-3161 TOWtl &. Country® Everett:(425)258-4171 • Puyallup:(253)840-9552 POST FRAME BUILDINGS Administrative Headquarters: (425)743-1555 IIIIIIINIMINII a FAX: (425) 742-4378.800-824-9552 ERMA BI LT Contractor's Lic.#:TOWNCPF099LT V DIVISION permabilt.com•facebook.co /:: r abilt Quality: Our Future Depends On It.' B e , °ell ve/) DIRECTIONS TO SITE /./ (WI - 9 20 15 l4/v ( c �/"�� JOB NAME: DEPTO1.rSO SHIP TO ADDRESS: nnnn f MyCOUNMON�rypEVEOPME Nr Y 45.6,1"144._ p,�g 39 3 TELEPHONE#AT JOB DROP: R f 6 377 .7/[-1 T' THOMAS GUIDE Can a semi'turn around at the job drop?, Yes CI No 111Back-inOnly El Other Can a two tone get into the job drop? FI Ye ❑No ❑Other Can a concrete truck get into the drop? 161 Yes ❑ No ❑Other Will a 4 wheel drive vehicle be required for deliveries? ❑Yes (®J NNo ❑GOtther D Directions ' tl y 14 77) /1(///W-CS 4151(4-,212 / d j l Tb Pd al 1C-1Aj 4A.764.Vc Q v a" . k-I` g417 /LD ; (LT 010 56:00 u i�,4 / )-A0c DA/ Lhej s'IZ DIRECTION I) 60-1 sly A. -row' YijoAT ac / 44 etc 0 4. t s .r v /4? t------K / slums F/€5 ve 'Truck Dimensions:65'long,8'wide, 121/2' high,and it weighs 35,000 lbs.empty. 1vDo /45,01,04.. 2Truck Dimensions:30'long,8'wide, 12/' high, and it weighs 18,000 lbs.empty. 02012 Perma-Bill®Industries FR-35 07/12 11011111111111111 • 411 6/10/2015 ShoId Excavating Inc. PO Box 179 _ -- 360. 385-0480 Port Hadlock, WA 98339 QIIECEGVE— PROPERTY INFORMATION ti i JUL - 9Location:391 SENTINEL FIRS RD L�15 PORT HADLOCK Tax ID:921193026 Macro: WILLIAM SNYDER JEFFERSON COUNTY Use; 351 SENTINEL FIRS DFPI OF CGM/I PORT HADLOCK,WA PILNI7YDEUFLOPMEM 98339 Owner.WILLIAM SNYDER ON ID:SOM08-00072 Feld ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT - Fold Here Inspected:03/1212015 - Inspection Type:PROPERTY SALE - Correction Status:No corrections needed "Bre Company: Certification-Level 2 Work Performed By: Submitted 03/13/2015 by: Shold Excavating Inc. Timothy Johnson Timothy Johnson This report does not assure approvals by Jefferson County Public Health for ANY future building permits or development. COMMENTS&GENERAL INSPECTION NOTES No Deficiencies Noted GENERAL SITE&SYSTEM CONDITIONS The General Site and System Conditions were: Fully Inspected All Components accessible for maintenance,secure and in good condition: YES n mo_.._ ge._..._ __.- ................. Surfacing effluent from any component(including mound seepage): NO o nts appear._. watertight leaks: Components ato be watertight-no visual YES mpr oa ._..o... . .._..._.. -.---"- .. ......_..._......_ Improper encroachment(roads,buildings,etc.)onto component(s): NO Component Po 9 Problems observed: NO Abnormal ponding present for one or more of the disposal components: NO Subsurface components adequately covered YES Owner compliance issues noted N/A ac. yes e... Site maintenance required(e.g.Landscape maintenance)If yes,describe in comments: NO e.... --_ p atin g p in --_.. Occupant compliance problem(occupant not operating the system properly). If YES,describe in notes: NO If deficiencies were identified on last inspection were they corrected before or during this inspection? YES (If NO,describe In notes,NA=no deficiencies on last report): OSS Components,structures and appurtenances located per as-builVrecord drawing(If NO,describe YES in notes). If no as-built exists or changes made,state NO and provide record to Health Dept: Alterations made to the OSS(valves adjusted,timer settings modified,ports installed,etc.)(If YES, NO describe in notes): The house/structure was vacant or used innas of frequently,assessment of the drainfield was not possible. NO Is the SEP case in a finaled/completed status?(if NO explain in comments) YES ONSITE SEWAGE SYSTEM INSPECTION DETAIL TANK:Septic Tank-2 Compartment 1000 Gallon This component was: Fully Inspected Component appears to be functioning as intended: YES Effluent level within operational limits(if NO explain in comments): YES All required baffles in place(N/A=No baffles required): YES Effluent Filter Cleaned(N/A=Not Present): YES Effluent filter/screen needed cleaning on arrival NO Compartment 1 Scum accumulation(Inches,if other specify): 4" Compartment 1 Sludge accumulation(Inches,if other specify): 2" Compartment 2 Scum accumulation(Inches,if other specify): 0" Compartment 2 Sludge accumulation(Inches,if other specify): 1•' Pumping needed: NO Approximate Gallons to be pumped(if needed)by Certified Pumper: 0 ReportiD:427225 View Inspection reports online at www.onlinerme.com Page 1 of 2 This component was: Fully Inspected Component appears to be functioning as intended: YES Compartment 1 Scum accumulation(Inches,if other specify): 0 Pump vault screen needed cleaning on arrival N/A Compartment 1 Sludge accumulation(Inches,if other specify): a Pump Vault Filter cleaned(N/A=not present): N/A Pumping needed: NO Approximate Gallons to be pumped(if needed)by Certified Pumper: o •ump:Effluent Pump This component was: Fully Inspected Component appears to be functioning as intended: YES Controls functioning: YES Dose setting different than original(If YES,detail in comments) NO Dose setting adjusted to meet as-buut/record drawing specifications(by the 0&M Specialist) NO Tested gallons per minute flow: 25 anal:Control-1 Pump Manufacturer:Aquaworx This component was: Fully Inspected Panel functioning(including alarm): YES Pump 1:on minutes(override in parentheses-if present): 1:26 Pump 1:off hours(override in parentheses-if present): 4:00 Pump 1:gallons per dose(override in parentheses-if present): 40 Pump 1:ETM hours(override in parentheses-if present): 42:10:51 Pump 1:Cycle Count(override in parentheses-if present): 1724 a rain field:Pressure This component was: Fully Inspected Component appears to be functioning as intended: YES Lateral lines flushed: YES Average squirt height(if performed)(feet,if other specify): 4' Ponding present?If YES explain in comments: NO D eoell r JUC - 9 2015 JEFFERs DEPT OFCArry -AlUNI N p�OPl4E Mf This report indicates certain characteristics of the onsite sewage system at the nitre of visit.M no way is this report a guarantee of operation or allure performance. ReportlD:427225 View inspection reports online at www.onlinerme.com Page 2 of 2 , 1RD UIL ING PERMIT APPLICA!N BLD15-00236 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00236 Received Date: 7/9/2015 SITE ADDRESS: --- SENTINEL FIRS RD OWNER: ROBERT HUBERT PHONE: 360-379-5454 391 SENTINEL FIRS RD PORT HADLOCK WA 98339-9763 SUBDIVISION: Block: Lot: PARCEL NUMBER: 921193027 Section: 19 Township: 29 N Range: 1E CONTRACTOR: TOWN &COUNTRY POST& FRAME PHONE: 425-743-1555 16521 HWY 99 SUITE C LYNNWOOD WA 98037-3161 Contractor's License TOWNCPF099LT Expires 6/30/2015 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW GARAGE NO PLUMBING - NO HEAT TYPE OF WORK GAR SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 33,292.00 ADD'L: HEAT TYPE: UH CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: 1,152 SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: 0 Prop: Prop: 0 Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $421.00 SRE 07/09/15 156237 Plan Check $273.65 SRE 07/09/15 156237 State Building Code $4.50 SRE 07/09/15 156237 Total: $699.15 11firlcm=r41r1oto1fnrmclF RI fl Ann RId rnf 7/Q Z- ) 7 • • [cl�� sON oo�� r DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 ti TeL 360.379.4450 j Fax:360.379.4451 j Web:wtvw.co.Jefferson.wa.us/communitydevelopment eck 4. , 9 E-mail:dcd�,co.jefferson.wa.us 1� � �� sHrNr3� i PERMIT APPLICATION ��' 'JUL ` 9 2015 Steps in the Permit Process: JEFFERSON p L_______ VvrOFCOIIIMUcoUNry -Review application checklist to ensure all information is completed prior to submitting application. DNrn'DEVEtOpME� -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not a standalone application;it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit# Related Application#s: MLA# Site Information r, Assessor Tax Parcel Number: 4071;14,-0-3-40cq! 2.)/ q 3 077 Site Address and/or Directions to Property: ft 0-/VT7144-- fl/ZS (O( il-cri /)—Tn) Pprtr- 1-G1401..41G4.- W A— j 3?9 Access(name of street(s)) from which access will be gained: f11Fi Present use of property: - V Description of Work(include proposed uses): P- qZ4,i.F_ G -G1 • Wastewater Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO Y X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: Community Septic Name of System: Case#: Are other residences connected to the septic system? N4 Additions or repairs to sewage system: Is it a complete or partial system installation: Complete A _____ Partial _ _ Has a reserve drainfield been designated? VA/ w 1✓ Yes _ No _ _ _ Date of Last Operations& Maintenance check: 14P'(c- 2.o 1 Attach last report to application Describe or attach any drainfield easements, covenants or notices on title,which may impact the property: The authorized agent/representative is th rimary contact for all project-related questioned correspondence. The County will mail /e-mail requests and information about the application to the authorized agent/representative and will copy(cc)the owner noted below. The authorized agent/representative is responsible for communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email(i.e., County email is not blocked or sent to"junk mail"). Applicant/Property Owner Information Property O ner: Name: 4,{1^ ., u,Yj0°} Address: �y/ efrtin e I F((rS Pcpc„---4- t,c{c11„(< w4- ? s?-337 Phone#: 3(40-3-79 '-S 5 S &/ E-mail Address: ('laic l(u 6 ti/'f (65 e O1.{n-�0,1, c-ern _ — Please c�o�act Authorized Agent/Representative with project info. (select only one . Property Owner Signature: ,C1 4 Date:s7..0_5 Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative(If other than owner) Name: 1 7vvW NI- GvuA/T Address: ((/c.-2.-) 4-44/14 Q9 Sig. C l-yivi . tela 1,.../0- 10037 Phone#: 46CA $2y/gSTL E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO A. YES Engineer Architect Surveyor /Contractor Consultant n2 Name: A/ tciN%ty / r, - < J /y 5 License# n rVr��o 9 c9 < T Address: /&5-Z7 4i,y 9 f� Sr/.e C Z yrciiv/_ ,n,,,D, Gu' 9P0 37 / Phone#: t/Zs.-7c/3-/s--� s- E-mail Address: //x.,/'14,,/iSe e. <<n¢6;/7.Ca - Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License# Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? '. i s Engineer Architect Surveyor Contractor . -"t ! W Name: License# Address: I L] L------ ----------1-1: I - 9 2015 I Phone#: E-mail Address: 1 _ JEFrFRe0 68bfJTY bEPL OF COMMUNITY DEUELOPMEM 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 or her 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I 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. Applicant may request notice ,, e /unnty's in ent to enter upon the property for vis• related to this application/ and subsequent permit issuance. '. signature:. Print° Print Name: ldie/''J p. />/Li/,,1,,,-/— Date: 01) /S' 410 • N �o DEPARTMENT OF COMMUNITY DEVELOPMENT (.. 621 Sheridan Street,Port Townsend,WA 98368 Td:360.379.4450 I Fax:360.379.4451 Web:www.co.jeffcrson.wa.us/communitydevelopment E-mail:dcd@a co.icffcrsonAva.us CZ Stf 1 N6 �0 SUPPI.FMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PE r Ii JO/ g 20 r c • rte . ` . .. '`r"�d � � • � 'gyp Owner Name: ,yam BEST Assessor Tax Parcel#: 92/ X30 Z 7 New pC Replacement Relocated Addition Repair Demolition *A separate permit is required Select One: Single Family Residence Modular Other 645,....„47-e list Proposed Building/Pro � ; J Number of floors r # new bedrooms existing total bed #new bathrooms existing total bath Heat Source � 3 � Select all that apply: Electric Heating Oil Wood Propane Enter the square footage(sq/ft)that applies in each field: ". M Existing Sq Residential/Commercial Main Floor Residential/Commercial Second Floor Additional Floors-heated/unheated Basement-unfinished Basement-finished space or habitable Detached Garage-heate u Bated i i ifj Z Attached Garage-heated/un ea ed Garage 2nd fl-unfinished storage Garage 2nd fl-finished space or habitable Carport-2 walls or less Deck-uncovered Covered porch Other(shed, barn, pole bldg,etc.) Estimated Cost of Project(Required): $ Supplemental SFR 1 • • List existing buildings on property jI e house,garagtie, accessory dwelling unit, shed, barn, mobile home,other): A�IExlstirig'Buil ing,on?roperty1.',;--1 ] ' r i;'; ' Use V, „ i £ = l , ,-.14441 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 making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applic.. - federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson ounty and its employees, representatives or agents for the sole purpose of application review and any require, later inspections. pplicant may request notice of the County's intent to enter upon the property for visits rel. -d to this applicat.'and subsequent permit issuance. Signature: ..� �� :�,�� Print Name: �Tctfc %v��t TT Date: Estimated Cost of Project $ Building Base Fees Building Base Plan Check Review Land Use Review - $228.00 Septic Review f , „- $79.00 ' C1 � � Potable Water i VJ ` $107.00 Technology/Scan In' ,J(JL _ 9 2015 $19.00 State Fee / Ll $4.50 EpIPy DEPT.OF JEFFC06IRSONRSQNCGUNyDE1TTnt-NrT Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt# Date: Cash/Check/CC: Supplemental SPR 2