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Home My WebLink AboutBLD2015-00083 - 01 PERMIT APPLICATION BUILDING PERMIT APPLIC•ION BLD15-00083 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00083 Received Date: 3/17/2015 SITE ADDRESS: 148 BROOKSIDE ST OWNER: HABITAT FOR HUMANITY OF EAST PHONE: 360-379-2827 JEFFERSON COUNTY PO BOX 658 PORT TOWNSEND WA 98368-0658 9365 SUBDIVISION: Block: Lot: PARCEL NUMBER: 936500006 Section: 11 Township: 29 N Range: 1V1 CONTRACTOR: DAVE GRAUBERGER PHONE: 360-643-3807 HABITAT FOR HUMANITY P.O. BOX 658 PORT TOWNSEND WA 98368 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NSFR SEP12-00087 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,280 VALUATION 147,798.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: OCCUPANCY: UNHEATED: #OF STORIES: OTHER: CONST TYPE: GARAGE: 32 SHORELINE: CONST TYPE: DECK: 160 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 05783 BEDROOMS: BATHROOMS: Exist: Exist: Prop: 4 Prop: 2 Total: 4 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,363.00 DWJ 03/17/15 154219 State Building Code $4.50 DWJ 03/17/15 154219 APP Potable Water Application $68.00 DWJ 03/17/15 154219 ROVED Plan Check $885.95 DWJ 03/17/15 154219 APR 15 2015 Total: $2,321.45 r \\tidemark\data\forms\F_BLD_App_Bld.rpt 4/15/2015 • S SONc DEPARTMENT OF COMMUNITY DEVELOPMENT cv O6. 621 Sheridan Street,I'ort Townsend,W/\98368 Tel.360.3%9 4450 I Fax:3GOs 24451 sv ti Web' wu co lefferson.wa us,commurvt�dcvclopmcnt E mail:dcd(a)co.jefferson.wa.as L 1SII NC'9 SUPPLEMENTAL APPLICATION j ! i! MAR 1 7 2015 RESIDENTIAL OR COMMERCIAL BLDG PERMIT ,.uiVrY For Department Use Only Receipt#: Date Related Application#s: Payment #: Site Information Owner Name: 1-,0,01 rl Lt 1 0Y kf\/Vl6 ux,{ f Assessor Tax Parcel #: 566 66(p Type of Building New X Replacement Relocated Addition Repair Demolition *A separate permit is required Select One: Single Family Residence x Modular Other list Proposed Building/Project Number of floors f #new bedrooms 4 existing — total bed # new bathrooms `_ existing total bath Heat Source Select all that apply: Electric )( Heating Oil Wood Propane Enter the square footage (sq/ft)that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office Use) �2esidential Commercial Main Floori l S{jQ I', �`D`(L: 'c' R i Sec©nd door Additional Floors- heated/unheated Basement- unfinished Basement-finished space or habitable Detached Garage - heated/ unheated Attached Garage - heated/unheated Garage 2nd fl- unfinished storage Garage 2nd fl -finished space or habitable — Carport- 2 walls or less Deck- uncovered —� Covered porch 1 OD t 0 ."t Other1(shedlbarn, pole bldg,etc.) 32 . G23`-( Estimated Cost of Project (Required): $ 3 s' ( 0Qo $ I List existing buildings on property(•house, garage, accessory dwelling unit, she , barn, mobile home, other): All Existing Buildings on Property Use N614 Builders Statement The signer of this statement certifies 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: Print Name: 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 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. TER i- W 1113 Ctf TI=Z o RE Signature: ` Print Name: /kWiy ME-K.-130Z.(2 Date: �'l? " lam Building Permit Fees Building Base ) 3 0 Plan Check Review Cl2) 5 • Land Use Review $234.00 Septic Review $80.00 Potable Water $109.00 Technology/Scan • $19.50 State Fee $4.50 Other Fees 2C0ci S (c Shoreline Exemption Zoning Zoning Other New Address 2L4. • U v Road Approach Total Fees 2_9 2_9 -cis- Receipt # cis- Receipt # Date: Cash/Check/CC: Prescriptive Energy Code Complilt for All Climate Zones in Washington ip Project Information Contact Information 'm" lillll _ This project will use the requirements of the Prescriptive Path below and incorporate the the minimum values listed. In addition, based on the size of the structure,the appropriate number of additional credits are checked as chosen by the permit applicant. Authorized Representative . Date 3— 13-Z ✓ ._ ' . mate- nes r,,,F . . ;�,1, ''," '''' 1 R-Value U-Factor" Fenestration U-Factor° n/a 0.30 Skylight U-Factor n/a 0.50 Glazed Fenestration SHGCDe n/a n/a Ceiling 4 ' 0.026 Wood Frame Wall'' 21 int 0.056 Mass Wall R-Value' 21/21" 0.056 Floor 30g 0.029 Below Grade Wall' 10/15/21 int+TB 0.042 Slab°R-Value&Depth 10, 2 ft n/a *Table R402.1.1 and Table R402.1.3 Footnotes included on Page 2. Each dwelling unit in one and two-family dwellings and townhouses,as defined in Section 101.2 of the International Residential Code shall comply with sufficient options from Table R406.2 so as to achieve the following minimum number of credits: [11.Small Dwelling Unit: 0.5 points Dwelling units less than 1500 square feet in conditioned floor area with less than 300 square feet of fenestration area. Additions to existing building that are less than 750 square feet of heated floor area. ❑2.Medium Dwelling Unit: 1.5 points All dwelling units that are not included in#1 or#3, including additions over 750 square feet. 03. Large Dwelling Unit: 2.5 points Dwelling units exceeding 5000 square feet of conditioned floor area. Table R406.2 Summary Option Description Credit(s) la Efficient Building Envelope 1a 0.5 ❑ lb Efficient Building Envelope 1b 1.0 ❑ lc Efficient Building Envelope 1c 2.0n%q S 2a Air Leakage Control and Efficient Ventilation 2a 0.5 1 2b Air Leakage Control and Efficient Ventilation 2b 1.0 2c Air Leakage Control and Efficient Ventilation 2c 1.5 ❑ ''\\ ' 3a High Efficiency HVAC 3a 0.5 LiqE;� �� ra, 3b High Efficiency HVAC 3b 1.0 ❑ —� 3c High Efficiency HVAC 3c 2.0 ❑ ,?' „,,,r,- 3d High Efficiency HVAC 3d 1.0 ' 1.0 4 High Efficiency HVAC Distribution System 1.0 ❑ 5a Efficient Water Heating 0.5 ❑ 5b Efficient Water Heating 1.5 [I]6 Renewable Electric Energy 0.5 *1200 kwh 0.0 Total Credits 1.00 *Please refer to Table R406.2 for complete option descriptions http://www.energy.wsu.edu/Documents/2012%20Res%20Energv.pdf • • ,930N (. DEPARTMENT OF COMMUNITY DEVELOPMENT cc 621 Sheridan Street,Port Townsend,WA 98368 tirC Tel 3611379.450 I Fax: 360.379.4451 Wchi xoivw.co.'efferion.wa.w./mint-num :develo.ment E-mad dc.d<ascojefferson.wa.us L-1) 15 - 0 46'/:I N-E--,,, �0 PERMIT APPLICATION (. �l V E Steps in the Permit Process: A � r; I -Review application checklist to ensure all information is completed prior to submitting a(�pfica�tion.tr il p 17 2015 -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. J ---1 -This is�nyot.._a standalone application;it must be accompanied by aproject specific supplemental a p Iitatiop.0dEfs sin pPMrNn T -Fees will be collected at intake. Additional fees may apply after review and payment is required be r "'_'- issued. ForDyea, enttisenl ( i :,'„ ,:;;;';,',,',V. i i iii ai s e II)i )(i $ " � vt 1 _ Ir!,ii ii.('z teN ii , , ii ilml ii 5 �) Iih , , i iwtele _ II it a ,i!i' _ ! t mat �i x � ii t < . iMLAlk!Ilil; _ ;{, iii iiih,lL Sitei on iIa . l ( 1 , - ! 1"..« Assessor Tax Parcel Number: ct% 560 cot,' 4.. /y Site Address, frannd/or Directions to Property: wt, z, Gd%tN 4.c.uw� eA E 145 &M . kut'yt I . Coatn VtaA &.7[ GN �i erWtfiir Wou4 i c,ult/l on JYCol ( (�Y� IS on (iPfi- 40,R,• Access(name of street(s)) from which accesslwill be gained: S{�ILtPiQCi Ems. Present use of property: u14ti Vb"LDP6-12 (dctvc' Description of Work(include proposed uses): geW 51,W& 14141 E2.1�2p,1 f " (E 1.,411-4- P tzt V t. 1 110 2 Piµ- StTe PW2tct J(' SPA(- . "`1 11 �e sposaF III�ir tl I tt .�y.Y«+` ,,i,l,„,,,, i, i_ = o tjiiii <..`' .y i This property is served by Port Townsend of Port Ludlow sewer system? YES _ _ NO ?C, x If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: — X Septic Septic Permit#: SSP\2. – 0 DOS7 Community Septic Name of System: Case#: Are other residences connected to the septic system? NO Additions or repairs to sewage system: ..-- Is it a complete or partial system installation: V(/Fj INS1 Complete _ _ Partial Has a reserve drainfield been designated? 1 ,eVisL 1/t' 1 k1ii-CPYes _ No Date of Last Operations&Maintenance check: t,Iod, 1Jb'C e,ealt t9'MA,*p 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 primary contact for all project-related questions and 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 a•Dstation. 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 IiiM M � $!m it k,i' `I ji iiii i' ) j y ii ir:Rr n' "Illy' ii ryii ." Property Owner: Name: 1•}1131,T1 `T FOte immitr Jt1\4 0r wT JErFVRSbNi avNly Address: tie) �527 ('0T-T `O SO4 PtwA Q83(08 Phone#: _ ,t20 . 37Q- Z 17 M °FC• E-mail Address: Please c tact Authorized Agent/Re resentative with project info. (select only one). 20(5NProperty Owner Signature: Date: 3-/?j-20/5— Note: ote: For projects with multiple owner attach a separate she ith each owner(s)information and signatures. ica i ,SE Sized '+Si.11 f!'4 E t 1 9fi rthano iner)ir r -'': .—'_ " Name: 91. VV &RM) 136R ) ur/ 1k1A-P,1,71*T rtta ttvMil-NlTl3 Address: �, Phone#: *b9 • �43 • $Q7 Ce,l # E-mail Address: �`'1, ( sat hQbjsGltG jG 01-1 ii ir -� v �i r Ila. PFS this an Awe Re w i t tive rata jest? ;,' �' Engineer Architect X Surveyor Contractor YNYi Consultan Name: P ilAC12C41-1TR/•TURE - fz-LGttY P I3 Address: 1t7 T /L2? Z 9T. i F412;1 TOt 4st 61Pl V)11, 1'83168 Phone#: gogO E-mail Address: rl'C 4a-Yd@ f - rrcfi n-c.rcLt •tow °Professio y this an Authorized� fie e et t f � hi itject : f YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: i 3i •xi er ii'€x III rte*^"� i Professions n,i hisan Authori edf gen Represent � I �I Ft)j s� €t YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: P ofessianal: Isthisan Auth diAgen ep entatiNe 'th prrject? "311-1(111;:NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Attach additional pages if necessary Builders Statd ° _ _ The signer of this statement certifies that they are the Owners of the parcel referenced herein,,'I-,:tTheq are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the.proposed project. r Signature: Print Name: Date: Mn '^ nth j • • SONco DEPARTMENT OF COMMUNITY DEVELO 621 Sheridan Street,Port Townsend,WA 98368 ,� L=r1 nM E Tel:360.379.4450 Fax:360.379.4451 -G Web:www.co.jefferson.wa.us/communitydevelopment I U E-mail:dcd(a7.co.jefferson.wa.us1MA I ;l R 1 7 2015 it- -4 SUPPLEMENTAL APPLICATION DETERMINATION OF ADEQUATE POTABLF,Ny , RDE IFLOPMENT Owner Name: -V l ((,Vt`'l/� "`Parcel No. % SID Oa(<7 a) J o9' Site Address: 7 812ro Water Source Existing Proposed Attach Copies of: 1) Well Logs Private well (if no log report on file,a 1 hr stabilization test may be substituted.) 2) Lab analysis tested within 3 years of application. -Total Coliform, Nitrate-N,Chloride 2-Party Well Items above AND recorded Operations&Maintenance agreement and recorded Easement. Alternative Provide justification and design per Jefferson County System: Environmental Health policy 97-01 www.jeffersoncountypublichealth.org/pdf/Polity 97-01_Rainwater_Collection.pdf Valid Water Right Permit: Generally applies to springs,attach copy. Public Water: Name of Water Provider: SU n -@ I -Submit Water Availability Notification form completed by your water purveyor. NOTE: If any of the above utilities need to be installed and disturbance will occur in a public maintained or unmaintained County road and/or Right-of-Way easement,then a Right-of-Way application will be needed. Resolution#99-90 requires building permit applications to provide evidence of an adequate potable water supply per the conditions of RCW 19.27.097 and the Guidelines for Determining Water Availability for New Buildings. 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 application 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 of the County's intent to enter upon the property for visits related to this application and subsequent permit issuance. Signature: Print Name: Date: FOR OFFICE USE ONLY 1) Water Right Permit# 3)Individual Well 2)Public Water Supply WS ID# Meets Water Quality Standards? Yes No In Compliance Yes No WRIA 17 Subbasin SIPZ -Coastal/Moderate/High Yes No Based upon information provided by the applicant,it appears that the potable water supply: Meets Conditionally Meets Does not Meet • <<, °G DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 98368 ` < Tel:360.379.4450 Fax:360.379.4451 Web:wwcv.co.iefferson.wa.us/cotnmuiutydevelopment !y E-mail:dcdeco.iefferson.wa.us '1"SWING C:) WATER AVAILABILITY NOTIFICATION PUBLIC WATER SYSTEM TO: Jefferson County Environmental Health Department FROM: (Water System Name) System Operator: State ID Number: Total connections for which system is approved: Number of service connections existing(in use): Number of service connections committed: Date and results of most recent water bacteriological analysis: / / The water system is capable of and will supply potable water to the following location: Assessor's Parcel ID#: Legal Description: Site Address: Operator Signature: Date: / /_ EXPIRATION DATE OF THIS SERVICE COMMITMENT: / / • • Public Utility District #1 Of Jefferson County WATER AVAILABILITY NOTIFICATION Board of Commissioners Barney Burke, District 1 PUBLIC WATER SYSTEM Kenneth A. McMillen, District 2 Wayne G. King, District 3 James G. Parker, Manager To: Jefferson County Environmental Health Department From: Quimper Water System System Operator(s): Eric Storey ,� - r M G State ID Number: 05783U ', , vt\,71 7 '2015 Number of existing connections: 2429 (Estimated) Number of permitted connections: 3149 rCOM1+iU��LOPMENI Number of committed connections: 25 12 This water system is capable of; and will supply potable water to the following location: Assessor's Parcel ID# 1 3 ' 500 0c1! LegalDescription �l'o0k-Si 0(G 74' --c5 t 1— (O (C)1/1 d U i/& 101,4— 1 Ac=-1- 4 ) cvb,) /yam lace *** Water Connection is available once all fees/charges have been paid*** Site Address: Signature: (.. Title: (S Date: 3//0//S THIS IS A NON-BINDING STATEMENT OF WATER AVAILABILITY. IT PROVIDES THAT AT THE TIMEOF REQUEST, WATER IS AVAILABLE WITHIN THIS SYSTEM. THIS NOTIFICATIOON IS GOOD FOR ONE YEAR 230 Chimacum Road/P.O. Box 929, Port Hadlock,WA 98339 PH (360)385-5800 FX(360)385-5945 4SON e ODEPARTMENT OF COMMUNITY DEVELOPMENT nn p �4, GS 621 Sheridan Street,Port Townsend, A 98368 W Tel:360.379.4450 Fax:360.379.4451 Web www.co.jefferson.wa.us/communitydevelopment E-mail:dcd@co.jefferson.wa.us .1SFrI NO ° �U J PERMIT FEES WORKSHEET �rY Fir FfrNT Name HABITAT FOR HUMANI Parcel# 936500006 Estimated Cost of Project $147,798.00 Permit# Building Base Fees Building Base $1,363.00 Plan Check Review $885.95 Land Use Review $234.00 Septic Review $80.00 Potable Water $109.00 Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning New Address $234.00 Public Works Total Fees $2,929.95 Office Use Only Receipt Number: Cash/Check/CC: Date: • BLD15-00083 BUILDING PERMIT APPLICATION Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD15-00083 Received Date: 3/17/2015 SITE ADDRESS: CHIMACUM RD OWNER: HABITAT FOR HUMANITY OF EAST PHONE: 360-379-2827 JEFFERSON COUNTY PO BOX 658 PORT TOWNSEND WA 98368-0658 9365 SUBDIVISION: Block: Lot: PARCEL NUMBER: 936500006 Section: 11 Township: 29 N Range: 11/1 CONTRACTOR: DAVE GRAUBERGER PHONE: 360-643-3807 HABITAT FOR HUMANITY P.O. BOX 658 PORT TOWNSEND WA 98368 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NSFR SEP12-00087 TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: 1,280 VALUATION 147,798.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: CONST TYPE: OTHER: 32 SHORELINE: GA CONST TYPE: DECKLE 160 SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: 05783 BEDROOMS: BATHROOMS: Exist: Exist: Prop: 4 Prop: 2 Total: 4 Total: 2 houtinq Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $1,363.00 DWJ 03/17/15 154219 State Building Code $4.50 DWJ 03/17/15 154219 Potable Water Application $68.00 DWJ 03/17/15 154219 Plan Check $885.95 DWJ 03/17/15 154219 Total: $2,321.45 \\tidemark\data\forms\F_BLD_App_Bld.rpt 3/17/2015 • • (r,,;IDN c,(-) DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,IN_A 98.368 Tel:360.379.4450 I Fax:360.379A451 \Xrcb: nvw.co.jcftcrson.wa.us/communircdccclopmcnt dcdiIco.jefferson.wa.us �9s17I r\" PERMIT APPLICATION Steps in the Permit Process: -Review application checklist to ensure all information is completed prior to submitting application. -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#5: MLA# Site Information Assessor Tax Parcel Number: q% 560 DO(o /� �Site Address and/or Directions to Property: fydyyl, ltvxGUI, cmc, 0064-C140, kUrkt t` . i atnr m S with 6.4" Cit Ivf-ite&i.Acir WA,U South en Brook-4 v, ?yCISvei-ti tS dA ( vest '3.i Access(name of street(s)) from which accessiwill be gained: gi J&D l a5 ST. Present use of property: ug ae UV,,ol ao2 (.msµ 7 Description of Work(include proposed uses): getAf Silo:1(91k' FitrittlA4 F. k ' (, ( '+4 94Vf✓'Wr Ick14V 2 ag- Str ecti2ActkIt� Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES _ NO )C, X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: NA Septic Septic Permit#: SV-P t 2 - O b 067 Community Septic Name of System: Case#: Are other residences connected to the septic system? NO Additions or repairs to sewage system: Is it a complete or partial system installation: W., (4d1. Complete Partial _ _ Has a reserve drainfield been designated? ft-VW,l MV/k kePYes X _ No Date of Last Operations& Maintenance check: k..V6P aJb'[ 6e0.1 (1dS"(M.tr*D Attach last report to application Describe or attach any drainfield easements,covenants or notices on title,which may impact the property: Ki Pt • • The authorized agent/representative is the primary contact for all project-related questions and 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 Applicant/Property Owner Information Property Owner: Name: Kik Wte• Rl1WLItotT4 or ET Jart .sf51 atiNly Address: jga •967( 0E) 4J�o?-f TO 3o4PiwA g83428 Phone#: _ %Q • 37q- Zg2I M4.414 6%• E-mail Address: Please c tact Authorized Agent/Re resentative with project info. (select only one). • , Property Owner Signature: Date: 3-13 -z/45-- Note: 13 -z/45- Note: For projects with multiple owner attach a separate she ith each owner(s)information and signatures. Applicant Authorized Agent/Representative(it other than owner) Name: 9cVc ( rz•Acu 13eieteGtz kg/ MI-tvPat'VT Fblz ttMlor ttl: Address: "� ,, • Phone#: �b9 • 643 • x$07 Ceti# E-mail Address: COw YUtI`O 'O? `lo.bi ytjc. • OrG!) Professional: Is this an Authorized Agent/Representative for this project? E YES' Engineer Architect X Surveyor Contractor Consultan Name: tia17Pcf $ AlZGR1TaiTUR - C2(Gt-17k1zP file(' Address: 1L7 -GI/(,01z ST. t ?D124 TO/AnkiSW4PI WP q8 36e) Phone#: 'NO •3I°) . } gag° E-mail Address: rCC.iaa.>r4@ {-exvaft n-Gtrat Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: _ _ .. Address: Phone#: E-mail Address: Attach additional pages if necessary Builders Statement The signer of this statement certifies 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: Print Name: Date: • • IzgON DEPARTMENT OF COMMUNITY DEVELOPMENT „4", 06, 621 Sheridan Street,Port Townsend,WA 98368 W Tel:360 3 9.4450 Fax:360.3'9.4131 ti '-C Web:www.co.iefferson.wa.us/commumtydevelopment E-mail:dcd@co.iefferson.wa.us 4., IS1I NOO� SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt#: Date: Related Application#s: Payment#: Site Information Owner Name: I-;(i 01\-0–t -C15itAAA Assessor Tax Parcel #: & 500 66 to Type of Building New X Replacement Relocated Addition Repair Demolition 'A separate permit is required Select One: Single Family Residence X Modular Other list Proposed Building/Project Number of floors i # new bedrooms 4 existing '-- total bed 2}- # new bathrooms 2 existing —' total bath 1� Heat Source Select all that apply: Electric )( Heating Oil Wood Propane Enter the square footage (sq/ft)that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (office use) residential' Commercial Main Floor ' .4 tie I ('L j p Res meccial_Second-Floor Additional Floors - heated/ unheated Basement- unfinished '— Basement-finished space or habitable :— Detached Garage- heated/unheated Attached Garage- heated/unheated Garage 2nd fl- unfinished storage Garage 2nd fl-finished space or habitable Carport- 2 walls or less –" Deck- uncovered Covered porch --- ft. i ( 0 Other(shed, barn, pole bldg,etc.) Estimated Cost of Project (Required): $ i35- ( 0 0� $ • • List existing buildings on property(i.e. house,garage, accessory dwelling unit, shed, barn, mobile home,other): All Existing Buildings on Property Use NcN Builders Statement The signer of this statement certifies 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: Print Name: 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 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. A -C.-0-re✓LTU'R-E Signature: / / 1. Print Name: Amy MK-13M Date: 3' L? ' l5 For Department Os Only Building Permit Fees Building Base Plan Check Review Land Use Review $234.00 Septic Review $80.00 Potable Water $109.00 Technology/Scan $19.50 State Fee $4.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Road Approach Total Fees Receipt Date: Cash/Check/CC: