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BLD2015-00037 - 01 PERMIT APPLICATION
• BLD15-00037 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00037 Received Date: 2/10/2015 SITE ADDRESS: 511 SCHWARTZ RD NORDLAND, 98358 APPLICANT: CHARLES HARTZELL PHONE: 18304 26th DR SE BOTHELL WA 98012 SUBDIVISION: Block: Lot: PARCEL NUMBER: 021291037 Section: 29 Township: 30 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW BUILDING PERMIT FOR A 1980 MANUFACTURED HOME SEP14-00093 TYPE OF WORK RES MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PEERLESS SETBACK: VALUATION 20,000.00 YEAR: 1980 LABOR& INDUSTRIES APPROVAL? SIZE: 70X28 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 05783 BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $546.00 SRE 02/10/15 154110 APPROVED State Building Code $4.50 SRE 02/10/15 154110 Potable Water Application $68.00 SRE 02/10/15 154110 18 Zgb Total: $618.50 Jeffers'; 1\tidemark\data\forms\F_BLD_App_Mob.rpt 2/10/2015 • c RJ • BLD15-00037 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00037 Received Date: 2/10/2015 SITE ADDRESS: 511 SCHWARTZ RD NORDLAND, 98358 APPLICANT: CHARLES HARTZELL PHONE: 18304 26th DR SE BOTHELL WA 98012 SUBDIVISION: Block: Lot: PARCEL NUMBER: 021291037 Section: 29 Township: 30 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW BUILDING PERMIT FORA 1980 MANUFACTURED HOME SEP14-00093 TYPE OF WORK RES MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PEERLESS SETBACK: VALUATION 20,000.00 YEAR: 1980 SIZE: 70X28 BANK HEIGHT: LABOR & INDUSTRIES APPROVAL? SEWAGE DISPOSAL: CON FLY Q` n eLQ`O2C1 a /1. 7/(G.A WATER SYSTEM: 05783 BEDROOMS: BATHROOMS: 1SS n 'F I ac PI4J Exist: 0 Exist: 0 Prop: 2 Prop: 2 A owner - �G7v ic' Q Total: 2 Total: 2 1e -Pitcc earl - ?eV r>1:I an Routing Date: hod 2/ 0/ 1S- Type Amount Paid By: Date: Receipt: Approved/Date Permit $546.00 SRE 02/10/15 154110 State Building Code $4.50 SRE 02/10/15 154110 Potable Water Application $68.00 SRE 02/10/15 154110 Total: $618.50 \\tidemark\data\forms\F_BLD_App_Mob.rpt 2/10/2015 . • • ����SON co G� DEPARTMENT OF COMMUNITY DE r.. 621 Sheridan Street;Putt Townsend,W.3 98368 I n s p v E _ 'Id:360.379.4430 Fax:360.379.4451 i r \\•ch n�ww.co jc•ffcrson.wa.us/communindcvcl< hrncnt !Li i ; i \ 1:-mad.dcd ncoicffcxsouaa'us 4 9 OS • I FEB 1 0 2015 g NINA.S SUPPLEMENTAL APPLICATIO IEITERSo:CCUNtY MOBILE OR MANUFACTURED HOME ,r ITyDF.rnnprrFn,? For Department Use Only Receipt#: Date: Related Application#s: Payment#: Building Information Property Owner Name:(. Ji .-te S (, 14,„,---t--.7 e /f Assessor Tax Parcel#: C) ( �,R ( ae3 7 Type of Manufactured Home: t Check One: New Replacement Moved i Demolition Check One: Park On a Lot I/ Temporary Construction Living Quarters Proposed Building/Project: Square Footage: Qcj, Number of Bedrooms: Type of Heating: ?)j__tf j• . Number of Bathrooms: Deck: c Sq/Ft: 6 7 Garage: o`ta Sq/Ft: Installer: C'Q S C Address, City,State,Zip: Y� Krt(1 4 8l 3 0 St m���f� elf�'f �1�,Cla Phone: (j_(0V3—/ 8 7& Installer Email: Contractors License#: K z f /A S . '7 C- 3 Assessor Information Home Data: Make: po_Q,V-- ,ss Model: 1.- 1 7 e Year: A 677 O Length 10 Width: cqQ Serial#: L./Z__ /© 6)<'"-t Your Purchase Price (Don't include sales tax): $/a Purchase Date: //g//J//""- Previous Owner/Location of Home(if new move to question next qu tion): From whom did you purchase your manufactured home: ya -0c Address -3,5--( In J L'ice'/ `J.E. i Or^cf_G\a rct 9836 6 co 0 Was manufactured home assessed in Jefferson County last year: YES 'NO ✓ 61 If yes, Previous address of manufactured home: ��3t5I 8Q/�h elm / �, �. P rc(ta , ri If no,what County was M/H assessed in last year: / - 5 x'366 Where is the manufactured home to be located: 4 Will the home be in a mobile home park? YES NO If located in a mobile home park: Name and address of park: /1//A If not located in a mobile home park: Name of land owner: 0-44.4e-S C , 41. vfze(( Location address: 511 t )c.k_l, t ,--L ,�NOv&Q t". Assessor tax parcel#: () f L' / 6' 3 --7 ---__ • • • /t5� .∎ rte I � i� C� i� rr`l "���\ JEFFERSON COUNTY I l l5 . 7 l i`, Ill _ti .Guth � t ---- --. , j% I ` ,. A�� Gc"'ARTt. . T OF CO Uf.l :vE C 'aEF' Li 1 ` _:: _ .:5 FE 1 C �u15 l'i I; \�''.r�._ .0/ .soot u . .o' F_..,.c � ' 1`J ts' Master Permit Application MLA cc n n croiect Description(include s_,;rate sheets as recessaryy,��_ _!^� v — -ax Parcel Nur„ber.Q a 1 c:261 I t 27 ---- _— r_ •• 77 _ 'r y Size �. lSJl�tq {ac;es;scuare feet Site Address and/or Directcns:c Preperv: S/ c SC- rva,r-i- . , fir, !J L 1 , ` 8 35-8 Property Owners)of Record: t , Ie-A e_C�'_ 7eepnona: 1--/G �q k, q pax: email l�+cv-iPS,C.FiQt�`f�P(� Ma;flrig Address:i_<3,fin' ��"-'LJr• S.C. ,C_ ,i.r a .c gC/a. LJbee ty . ,4 . c ► ApplicanUAgent(if different from owner): /�/ Telephone: Fax: � . email: Mailing Address:__ Wh-5.t kind of Permit?(Check each box that applies ❑Lot or Road Segregation 3?&ti!ding 0 Critical Areas Stewardship Plan Dernolition Permit C Variance(Minor. Major or Reasonable Economic Use) 9 }le Family 9 Garage Attached/Detached 0 Conditional Use[C(a).C(d),or Cl"' tv'anufactured Herne 0 Modular 0 Discretiona:-"D" or Unnamed Use Classification Cornmerciai" ❑Special Use(Essential Public Facilities)" 'T Change of Use 0 Boundary Line Adjustment 9 Address 0 Road Approach ❑Short Plat :0 eTome Business 0 Cottage Industry ❑Binding Site Plan "' ."_-J Propane C Long Plat" 9 eegn ❑Platmeo lkurat Residential Development(PRRD}IAmenciments " 9 Allowed'Yes"Use Consistency Analysis 0 Plat Vacation/Alteration" la Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions " C Site Plan Approval Aovance Determination(SPAAD) R ❑Shoreline Management Substantial Development" ❑Temporary Use 0 Shoreline Management Variance 0 Wireless Telecommunication. 0 Comprehensive Plan/UOC/Land Use District Map Amendment C Forest Practices Act/Release of Six-Year Moratorium C Jefferson County Shoreline Master Program Amendment 'May require a Pre-Application Conference 0 Tree Vegetation Request —. "Requires a Pre Application Conference Please identify any other local, state or federal permits required for this proposal, if known: I DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). 1 O::'NER SIGNATURE I Date: By signing this application form.toe owner/agent attests mat the information provided here n•and to any attachments.is true and correct to the best nr • his.her or ita knowledge. Any materia!falsehood or any omission of a material fact made by the owner/agent with respell to this application packet may result in this permit being null and void. ' • I limner agree to save,indemnify and hold na rnless Jefferson County against all liabilities itcements,cocR costs,reasonable attorney's fees and ex:rinses v. -ch may in any way accrue against Jefferson County as a result of or in consegcence of the granting of this permit. I *_".her agree to provide access ar:d right of entry to Jefferson County and its errp:oyees,representatives or agents for the sole purpose of application e• r and any re ou red Or inspectors, Staffs access and right of entry will to assumed ur'ess the applicant informs the County n venting at the ms of the application that he or she wants prior notice. I Signature: Date: T°e action cr actions Applicant will undertake as a result of the issuance of this penrit may negatively impact upon one or mare threatened or e:,angere•d species and could leac to a potential take" of an endangered species as those terms are defined ie the federal law known as the 'Endangered Species Act"o."ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this peiinit has teen issued wit not violate the ESA. Any individual,group cr agency can`te a lawsuit on behalf of an endangered species regarding your action(s)even if ycu are in compliance with the Jefferson County development code Tne Applicant acknowledges that he,she or it i .r:ivetual an:noneransferable responsibility for adhenrg to and comp'ying with the ESA The Applicant has read leis disclatmer and signs and oates it below. Siy,eivrc. ,_— ____ Date' - IN • • _______, .-:. ..:=.-..,__ :.-_..-z,::-:,.. -..,. ..':,. -,-..-.,:-..."7'.',:: •••-•,-.:-:.'; :::.. ; . - , . :•.::L.-7E"..7-F_-...-: '..:-.Hr., • t,;_;!::::,z.,-Z:4''EF.:=.• erojec, Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:— New X Wood Exist:1-g 2, 1 : - Sewe! : Addition 1 7 sir-el Propose: 2 __ Bank 1 2 Comrp,mity Syste.-n i - l'.itl _) . Heigl- 2 Alterationiftemoael ,- ra : __ q.Concrete : )' Indvidira.System: Repair ; 2 Masonry 1 —iliitli : SEP Permit tr _' Dernolii:co ; 2 °tr Bedrooms: ier: i 1 Water Supply: Ex.s:ing: _. ______ I Setback: I ..-i: Private well : Two Party 1 Type of Heat: i Proposed. 7... Total y Public Name of System: 1 . . . • 1 — ___ ._ l(this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Numoer of ADA Parking Spaces: , Number of occupants (includes owners,tenants,employees. etc) Current Proposed i :3C Ooopzincy: iGC Type of construct:or.: Wili you have Food Service? Yes / No 1 if this is a Propane Tank andlor Appliance Installation permit,mark all items below that apply: i Undergroiind Tank i Above ground Tank Size e Propane Tank: . i Heal Stove I Cook Stove i INocdstove 7 Fireplace 1r:sea f Het Water Tank 1 Pellet Stove i Other Is this appliance being installed in a Manufactured I Mobile Home? Yes i 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, includinq the reserve area. 17— -1---- 1 Square Footage Current Proposed For Office Use Only Amount 1 Revision —Main Floor Heated I EH Bid App Review: I le" I g3 NI I . 2'Floor Heated Consistency Review: ! A14 I Other Heated Base fee: I /V A Firariirie i Additional Section: , tt/ A Healed Basement I ! Plan Check fee: 1 . Unheated Basement 1 State Surcharge fee: ----1 . . . i Other Unheated Pot INater Review fee: I : NA — r : Garage/Carport SUBTOTAL Decks i : 911/Rd Approach fee. . . ‘ . ? ____ 0:her TD A..: ! $ • _ .1----- • . t • 1 Receipt Number: 1 :' • i Cash/Check Number: 1-- ESTIMATED COST (REQUIRED) Date: ' i •Fairmerkf,q%,atue of a,li labcr and niateri8!s i•;n1.19:;on k.,f:ti:5.4 L. 42 a 000,f-51 initia:s: . ! . .._ _ • . . .. . . . . •• .... • . . . .. . . . - . • • STORMWATER CALULATIONS—IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area) 1 700 sq/ft Structures(all roof area) 0 sq/ft Sidewalks 0 sq/ft Sidewalks 0 sq/ft Patios 0 sq/ft Patios 0 sq/ft Solid Decks 0 sq/ft Solid Decks 0 sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads,etc 2000 sq/ft Driveway, parking, roads,etc 0 sq/ft Other sq/ft Other 0 sq/ft Total New 3700 sglft Total Existing 0 sq/ft TOTAL NEW+TOTAL EXISTING` 3700 sq/ft 'This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: 0 % Does the site have 35%or more of existing impervious surface? Circle: Yes No I• 1 FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of "medium" projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation Worksheet,I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property. / , Al � _/ / //-C /$ ••• - THO' REPRESE'�ATIVE SIGNATURE) (DATE) IFOR OFFICE USE ONLY I SMALL MEDIUM LARGE REDEVELOPMENT Stormwater Site Plan: Yes No stormwater talc worksheet—REV.10/202014 2 • f 0 • k�,"?'"S°N e06. DEPARTMENT OF COMMUNITY DEVET.OPM '1 Q VE k et■ 62l Sheridan Street,Port townscnd,Wd 98368 i ti .1d.360.379.4450 Fax:360.379.-1451 � Web:www co iefferson.wa.us/conununintlevelo clop i i 1 E-mail:dcdrrCro.iefferon wa.0 i FEB 10 2015 II' �I`s�INCs`co i_____ Li CIAMY STORMWATER CALCULATION WORKSI-1<L'E`f " ''Y0' "' ''T _ __i M LA PROJECT/APPLICANT NAME: DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application,building permit application,or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE (I.E.,SITE) Size of parcel 1'8 acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 78408 sq/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative)and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing,grading,filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds,that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,and salal; herbaceous plants such as sword fern,foam flower,and fireweed. LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded, filled, Answer the following two questions related to excavated,and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: 2000 Does the project convert%acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank,etc. 2000 sq/ft Circle: Yes No Well, utilities,etc. 1000 sq/ft Does the project convert 2'%acres or more of 4000 native vegetation to pasture? Driveway, parking, roads,etc. sq/ft Circle: Yes No Lawn, landscaping, etc. 400 sq/ft Other compacted surface,etc. 0 sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 9400 sg/ft Cut 0 Fill 0 (cu/yd) Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops,walkways, patios,driveways, parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen materials,and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. stormwater talc worksheet—REV.10/20/2014 1 • • • ��w� s°N co&� DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street,Port Townsend,WA 95363 .-C Tel:36:.379.445O : Fax:360.379.4451 Web:www.co.jef terson.wa.tis/commurut�zlet'elo L : C O V E r� E-mail:dcdaco.iefferson.�la.ts / J 1J i_i .1,s,. -Ili - r, FEE 1 0 2015 'I.i PERMIT APPLICATION ! • ! i Steps in the Permit Process: Pi4ry Y DEVFLOWFNT -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#s: MLA if Site Information Assessor Tax Parcel Number: CO I — c.9- I – 0 R-- } ` Site Address and/or Directions to Property: Si 1 Sc�U;o./4 Z U - NCvdi l c-,,t V'■ /A Access (name of street(s)) from whit access will be gained: 7GA(,Ua r- Z /4. Present use of property: m to e/-j 6/ ( Description of Work(include proposed uses): 5L7 ,(1 rest danc . Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES NO L If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: � Septic Septic Permit#: 01 Community Septic Name of System: Case #: Are other residences connected to the septic system? Additions or repairs to sewage system: ,h.. , itrl) P CA.__.)Is it a complete or partial system installation: Complete Partial Has a reserve drainfield been designated? Yes ✓ No Date of Last Operations & Maintenance check: /1/ / A- 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 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 Owner Name: Ol1.Gt.Y` 'f.. 0.4,--4 ` f0—e-i( Address: t g 3( � oi„,, 5. _ 60-FI -e-/ ( (-J4 _.q go f/ j Phone#: 3 t-,O L f 6/_,yo E-mail Address: cjuk, `'E.�S re_„, fl y j e / bod y Please contact Authorized ■gent/Re. -sentative with project info. (select only one . GP rk Property Owner Signature: [�r-a.+--c`° C . Pl ' / Date: I z / is 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: Address: ,,\ t,CJ L-- Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Se (�' Contractor Consultant Name: Address: n) ow A l f2, Tb i ) I L-1 Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: Address: Phone#: ..:1 A,Hress: Professional: Is this an Authr .g � �w_.._ NO YES Engineer Architect ( Q�a(1 Consultant Name: 1 yt �— it Address: ( T Phone#: Professional: Is this an Au NO YES Engineer Architect �I1� ' - " Consultant Name: V 'tV r\ (_ ( Address: " `�-eV Phone#: �( Attach additional pages if neces.,�. , Builders Statement CUJCIPJ' e,i( . i � LY`l The signer of this statement certifies that they are the Owners f the parcel referenced herein, that they are not licensed contractors and that they will be assuming the response pity of the General Contractor for the proposed proj ct. Signature: iPrint Name: S Date: . S ,s°N DEPARTMENT OF COMMUNITY DEVELOPMENT W621 Sheridan Street,Port Townsend,WA 98368 Tel:360.379.4450 Fax:360.379.4451 Web:nw,•.co:effetson.wa.us/communittiiievelo E-mail:dcdm co.jeffetson.wa.tu f i YSkINGtO jr FEB 1 0 2015 PERMIT APPLICATION (! Steps in the Permit Process: ! JFFFERSa COUNTY OPT OF COMMUNITY DEVELOPMENT -Review application checklist to ensure all information is completed prior to submitting app'cation. -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 Assessor Tax Parcel Number: 4 - 3 Site Address and/or Directions to Property: Si Schwa/4-z. .& . Nerd ic.nd W lt} Access(name of street(s)) from whit)access will be gained: Present use of property: ®rPh Spy Description of Work (include proposed uses): -hp 5e " ibtp aL r~e s 1 cI Py,c e Wastewater-Sewage Disposal This property is served by Port Townsend of Port Ludlow sewer system? YES NO V- If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: I - 9501. Community Septic Name of System: Case#: Are other residences connected to the septic system? Additions or repairs to sewage system: /Lei d'l- ci P J Is it a complete or partial system installation: Complete t/ Partial Has a reserve drainfield been designated? Yes ✓ No Date of Last Operations& Maintenance check: ` ,4. 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 isThie primary contact for all project-related questions and correspondence. The County wil 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 Owner. Name: eri t a -/ �J e tz—e Address: /g3 r d'D Ld„_ _ , (364- e /p/ — q L sxor, Phone#: 3 ( b —LA,/___6e E-mail Address: ,4 q C_ , A,y S i/ 1 Please contact Authorized 'gent/Rep.resentative with project info. (select only one . Property Owner Signature: �:� ° C ✓�� ' / Date: '��Z 77S i Note: For projects with multiple owners,attach a separate sheet with each owner(s)information and signatures. Applicant: Authorized Agent/Representative (it other than owner) Name: Address: (\( j Phone#: J E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Se (-2 Contractor Consultant Name: Address: 1/1 i5 at„tY A, T. A. l"1 LJ f t Phone#: E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: _ Address: Phone#: -" A,+aress: Professional: Is this an Auth, ( it NO YES Engineer Architect ' ©rah Consultant Name: K t }— Address: t poTeer, Phone#: Professional: Is this an Au NO YES Engineer Architect Consultant Name: OAl ner 6- Vp�/ Address: �--t' Phone#: �( 4,,,, Attach additional pages if nece�..`.., \ l/ Builders Statement l .)--1.t" \ef' S ow, rQJ'�. J The signer of this statement certifies that they are the Owners df the parcel referenced herein, that they are not licensed contractors and that they fw+ill be assuming the responsi 9 ility of the General Contractor for the proposed projc�ct�. Signature: e LJ Print Name: / tS 0 Ci Date: �'rP 6'---- ' • • I s ��°N co� DEPARTMENT OF COMMUNITY DES 4 : iE 0 V E 44 - +t, 621 Sheridan Street,Port Townsend,WA 98368 1 I Li? I ti Tel:360.379.4450 1 Fax:360.379.4451 I 17',', 1 Web:www.cojeffuSOn.wa.lts/cormrnlitydcvelopnlcnt I l I FEB Q 2015 4_ 1 -rnatl:rJcd atio.iefferson.wa.us j �S'FI j N GI. � JEFf ERSOr1'COUNTY L"' ^MyiUNITY DEVFLOFMEPiT STORMWATER CALCULATION WORKSHEET` MLA# PROJECT/APPLICANT NAME: DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as "small," "medium," or "large." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan, if required. PARCEL SIZE(I.E.,SITE) Size of parcel 1.8 acres An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet 78408 sq/ft Land-disturbing activity is any activity that results in movement of earth,or a change in the existing soil cover(both vegetative and non-vegetative)and/or the existing soil topography. Land disturbing activities include,but are not limited to clearing,grading,filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds,that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir, western hemlock, western red cedar, alder, big-leaf maple, and vine maple; shrubs such as willow, elderberry, salmonberry,and salal; herbaceous plants such as sword fern,foam flower,and fireweed. • LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared, graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: 2000 Does the project convert'/.acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfield, septic tank,etc. 2000 sq/ft Circle: Yes No Well,utilities,etc. 1000 sq/ft Does the project convert 2'/2 acres or more of 4000 native vegetation to pasture? Driveway, parking, roads,etc. sq/ft Circle: Yes No Lawn, landscaping, etc. 400 sq/ft Other compacted surface,etc. 0 sq/ft Indicate Total Volumes of Proposed: Total Land Disturbance 9400 sq/ft Cut 0 Fill 0 (cu/yd) Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops,walkways, patios,driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads, packed earthen materials,and oiled,macadam or other surfaces which similarly impede the natural infiltration of stormwater. stormwater calf worksheet—REV.10/2012014 1 • r..1yovC�` DEVELOPMENT _ ECIFWET1 F=ERSO : COUNTY 1 ti � JE l .. i ',:,. • ,\ DEPARTMENT OF CC �„i,, , as FEB 1 0 2015 �.� �� JEFFERSON COUNTY MasterPert111f/app Application '.IFPT.OF COMMUNITY DFVFIOPMENT Project Description(include separate sheets as necessary)' _ ' Tax Parcel faun t r.Q a l aq 1 n37 ,.F o peay Size h l) ztr/L_Fte, (acressyuare feet Site Address anpd/or Direct:ens tc Property: C$C.i/t(A-Xt I • , { c- �k rop erty Owners)of Record; V M��t I - Telephone: 36,0 - 4/(:)/ - ,q 'y Fax: I __ ernait rilavrr S.C./laf 'ef( Mailing Address:L A .__- ` , " ,�i,rt ., I a. gO/. V bOel .C_TJVY� ApplicanCAgent(it different from owner): 4/ /A i Telephone: Fax; -- email: —. Mailing Addr=_ss: — What kind of Permit?(Check each box that applies • ❑Lot or Road Segregation Ir?Suiiding ❑ Critical Areas Stewardship Plan Demolition Permit ❑Variance(Minor. Major or Reasonable Economic Use) �_ yle Family ❑Garage Attached I Detached ❑Conditional Use[C(a), C(d),or Cj•" Er Manufactured Hnine ❑ Modular ❑Discretionary`D' or Unnamed Use Classification L Commercial" ❑Special Use(Essential Public Facilities)" r • ange of Use ❑Boundary Line Adjustment 40 Address 0 Road Approach ❑Short Plat" 7 i•lome Business 0 i Cottage Industry u Binding Site Plan"• S Propane 0 Long Plat" 0 3iyn ❑Plartnea tkurai Residential Development(PRRD)/Amendments •" 0 Allowed'Yee Use Consistency Analysis 0 Plat Vacation/Alteration'• 0 Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions •" 0 Site Plan Approval Aovance Determination(SPAAD) • 0 Shoreline Management Substantial Development•" 0 Temporary Use 0 Shoreline Management Variance 7_Wireless Telecommunication" ❑Comprehensive?:an/UDC/Land Use District Map Amendment 0 Forest Pract c•es 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: ■ ,C r c__Sr - n per mif SE PT/V- dog 93 — ---1 DESIGNATION OF AGENT 1 I hereby designate, to act as my agent in matters relating to this application for permit(s). I OWNER SIGNATURE Date: i 0y raping this application form,the owner/agent attests that the information provided herein,and in any attachments.is true and correct to the best of ~ n:s her or rs 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 I furtder agree to save,indemnify and hold naenless Jefferson County against all naaiiities j,,cements,court costs,reasonable attorney's fees and I expenses v.l1c.11 may in any way accrue.against Jefferson County as a result of or in consequence of the granting of this permit, I a.ther agree tc provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application rev ew and any required later inslxacttons. Staff's access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application that he or she wants prior notice. Signature: -- — Date: 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 leac to a potential 'take'of an endangered species as those terms are defined in the federal law known as the Endangered Species Act'o "ESA"Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has teen issued wilt not violate the ESA. Any individual,group Cr agency can`i:e a lawsuit on behalf of an endangered species regarding your actions)even if you are in compliance with the Jefferson County development code The Applicant acknowledges that he.she or it 1".0::,7- individual era nonaransferable responsibility for adhering to and complying with the ESA The Applicant has read this disclaimer and signs and dates it below, Sign2:ur ._.._,.._..._ _ , Date • r ..,a',: ligi . yam:.• v._:....-"Y`s .._..- ...-�_..._............ ... , Prelacy ype: Frame Type: Eatnrccros Shoreiine: ; Type of Sewage Disposal: P New ,X ,,loed ..stir^g. 2 I : Sewer Addition I 1 Steel i P . :Osec _..— bank , Cenn pty Sys e.r i te'atop;temocel Concrete s-.a! "L , Height: 7 Individ,ra,Sysie,' Repair = Masonry ' SEP Permit# _ Der7cliton Other: Bedrooms: I Water Supply: i Ex.sting, ,____. I I Setback: p Type of Heat: Pro^asad: 4 Private well wo Party `j7?ubf{�qt ata. _ Name of System: I I -- I — ___I . 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 ;GC Ocoupuncy: 16C Type of construction: Will.you have Food Service? Yes t No I If this is a Propane Tank and/or Appliance Installation permit,mark all items below that anoly: I Unde'gro,lnd Tank t Above ground Tank Size of Propane Tank; Heal Stove I Cook Stove I Woedstove = Fireplace insert I Hot Water Tank i Pellet Stove I Other _ Is this appliance being installed in a Manufactured I Mobile Home? Yes i No { When applying fora permit to install a propane tank you must also submit a she 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 I Current Proposed For Office Use Only Amount 1 Revision I vinin Floor Heated � EH Bid Apt Review: i 1840 2` Fioor Heated nsistency Review: I Other Heated A N I I Base fee: Mezzanine I Additional Section: + Healed Basement Pian Check Fee: I Unheated 'Basement —._.._._ .__ ----._.__ �� i Stale Surcharge fee: ! LL-------`-- ----�- i Other Unheated ---- - Pot Water Review fazes---- Garage/Carport NA� SUBTOTAL -� Decks i r ? I } 9111Rd Approach fee: 46.l Other - . -_.._ __ -___.._ –TOTAL ' 5 : Receipt Number: 1 Cash/Check Number. ESTIMATED COST - - -` ---I (REQUIRED)( ) Date: I- •Fairroad el vafije of all rabc and.7tai&rials towldal on to i.:ii5j> ii L�_ __ 42 a OOt2,n i Initial: — _ r o S All Existing.Buildings on Property g Use t shed, barn List existing buildings on property(i.e. house,garage,accessory dwellin g unit, , , mobile home o • :^ 1 0 2015 ,\ Public Health Information ,, ; rt ? GAT c,-c, � Water Source Existing Proposed Attach Copies of: Private well 1) Well Logs(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. http://www.jeffersoncountypublichealth.org/pdf/Policy_97- 01_Rainwater_Collection.pdf Valid Water Right Generally applies to springs, attach copy. Permit: Public Water: ✓ Name of Water Provider: r (L 0 # J r 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.http://www.co.Jefferson.wa.us/commissioners 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 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. / // Signaturr4. ,.S,. 1, (' L4 Print Name:�i,A t—/ S 5 iv Z q Date: aC /� 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 • • • e.° Utility District #1 �� , ubhc ty loc) 1!1 ' Of Jefferson County 11�, F E8 • v ,1``, ATER AVAILABILITY NOTIFICATION Board of Commissioners C� 0\0° Barney Burke, District 1 of Kenneth A. McMillen, District 2 PUBLIC WATER SYSTEM Wayne G. King, District 3 James G. Parker, Manager To: Jefferson County Environmental Health Department From: Quimper Water System System Operator(s): Eric Storey State ID Number: 05783U Number of existing connections: 2429 (Estimated) Number of permitted connections: 3149 Number of committed connections: / lh �� r de1`' �c This water system is capable of; and will supply potable water to the following location: Assessor's Parcel ID# a I a / 03'7 LegalDescription S�cfloh �� / b�nS1i ? 36 1\I Haviac I E ;9 7"3o C/ *** Water Connection is available once all fees/charges have been paid*** Site Address: 5/f 3C11 wart 4-1_ A I trrikald Signature: 67/1,4 1"'`„2, Title: it !Ai - Date: 1 /3 ) J 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 • • ���¢S°N co DEPARTMENT OF COMMUNITY DEVEtR T a v 621 Sheridan Street,Port Townsend,WA 98368 D ti A Tel 44 360.3'9 50 l Fax 360.379 44.51 Web www co iefferson v.1.us/commnnitydevelopment 4. 1' mail:dcda en 1efferson.wa.Lis f--\ ,1 F E B 1 0 2015 1 o "SNrNG� SUPPLEMENTAL APPLICATION JEFFERSON COUNTY MOBILE OR MANUFACTURED HOME; of coMMUN1rrDE;,rioPff For Department Use Only Receipt#: Date: Related Application Us: Payment#: Building Information Property Owner Name:L r S ( , y-t-7 e (/ Assessor Tax Parcel#: ice) ( „)...61 L C,37 Type of Manufactured Home: t Check One: New Replacement Moved ✓ Demolition Check One: Park On a Lot V Temporary Construction Living Quarters Proposed Building/Project: Square Footage: `p � p�� Number of Bedrooms: .� Type of Heating: ___ C_____ Number of Bathrooms: Deck: Sq/Ft: 6(/ Garage: V'L0 Sq/Ft: Mob /`i' 011�e tr'(t �N 1 . Installer: �M SS/ r / r Job/('e- Address, City,State,Zip: elf/f raja ,j.q gi 3 9 Phone: �,�—(�,y..3—/ '7Pp Installer Email: V Contractors License#: KO Z-e A S a°7 3 Assessor Information Home Data: Make: PQ,e-f- k. 5 Model: 1.--1 F%eirf--y Year: / 7V(7 Length '" C1 Width: �1 I Serial #: `/�- L_ / i�O ,) U Your Purchase Price (Don't include sales tax): $/1 9� Purchase Date: //2 //- Previous Owner/Location of Home(if new move to question next qu tion): From whom did you purchase your manufactured home: 'P/-'yfrV9'�+I er- Address 535 ( /7/?eta/ .. 5.E. . Perri" CJ�^cardL. .98366 03 a Was manufactured home assessed in Jefferson County last year: YES NO I/ If yes, Previous address of manufactured home: tom/ 8C/fm f iC C�, ,5, E. i0 q Al If no,what County was M/H assessed in last year: \/ TSQ p 51366 Where is the manufactured home to be located: 4 Will the home be in a mobile home park? YES NO t/ If located in a mobile home park: Name and address of park: N A If not located in a mobile home park: Name of land owner: ( 4-4,4e-S C, 7&10 Vtze./ Location address: 51/ ((3C./. .I.e.41-14-2- .,&/04f Assessor tax parcel#: (`)a/ aq1 0 37 • • • • STORMWATER CALULATIONS–IMPERVIOUS SURFACE NEW EXISTING Structures(all roof area) 700 sq/ft Structures (all roof area) 0 sq/ft Sidewalks 0 sq/ft Sidewalks 0 sq/ft Patios 0 sq/ft Patios 0 sq/ft Solid Decks 0 sq/ft Solid Decks 0 sq/ft (without infiltration below) (without infiltration below) Driveway, parking, roads, etc 2000 sq/ft Driveway, parking, roads, etc 0 sq/ft Other sq/ft Other 0 sq/ft Total New 3700 sq/ft Total Existing 0 sq/ft TOTAL NEW+ TOTAL EXISTING* 3700 sq/ft *This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v. REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: 0 Does the site have 35%or more of existing impervious surface? Circle: Yes pi No 1 FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPS) Packet. Proponents of "medium" projects—those that must meet only Minimum Requirements#1 through#5—and for"large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation Worksheet,I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property. It, .0 ".7'•1/ TH O Er-REPR ESE'r ATIVE SIGNATURE) (DATE) F'Ukdlril E USE ONLY .. 6 r SMALL ;MEDIUM ' 3,4RHE REDEVELOPME1@F� Stormwater Site Plain Yes„ .. stormwater talc worksheet-REV.10/20/2014 2 hcu • ��SO1v co DEPARTMENT OF COMMUNITY S A_ _ ! • • Begin Time: End Time: �sc�N rO DEPARTMENT OF COMMUNITY DEVELOPMENT w t:] ,. 621 Sheridan Street,Port Townsend,WA 98368 -< Tel:360.379.4450 i Fax:360.379.4451 Web:www.co.Jefferson nwa.us/communitydevelopment Q_ > E-mail:dcd(aico.iefferson.wa.us l'S'yi I N Cs'O Customer Assistance Intake Form Help us provide you the information you need by filling out this form. This is a public information form,the contents of this form is available to view by the public. • The first 15 minutes of staff time is free. Office Use Only • After the first 15 minutes, a minimum of one hour will be Receipt#: charged at the rate of $78.00 a hour with additional time over one hour billed in 15 minute increments. Check/CC#: • Please complete form and submit to the address or email Date Paid: above and a staff member will contact you. • Our goal is to respond within 14 calendar days of the request. Received By: n a NAME: 1¢IF1i2i.,e S c /��i9.2'7--2E LL DATE: //3 /S EMAIL ADDRESS: C"1—f1*''S,C. rlc�✓'rze-6� e4-'e/e70: COL41 MAILING ADDRESS: / u.icy 2L M- I.) S€ & .LL, W4 7&3( Z TELEPHONE: (HOME) _ 3&jD, L/4/ ( , (CELL) 5c'-fn'e PLEASE NOTE: Information and guidance provided through Customer Assistance is advisory only and is based on information provided by the customer. This is not intended to be an exhaustive review of all potential issues.Any discussion or information provided shall not bind or prohibit the County's future implementation or enforcement of all applicable laws and regulations. No statements or assurances made by County representatives shall in any way relieve the applicant of his or her duty to submit an application consistent with all relevant requirements of County, state and federal codes, laws, regulations, land use plans,and other requirements. Your Signature:- 0%"� � Monday, September 29, 2014 • Begin Time: End Time: Customer Assistance Intake Form Page 2 of 2 Information Requested - List all questions and any information you need addressed. Attach additional sheets of paper if necessary. N ; S/ epee - Lcr�,, -_�...a � S Chi ct.0 r'f / L �- WQ,ri -/-o C-1 C'c b l ' e i-'i 4-,rl d ^_ 4/50 leapt t ho �6 C -- 6 LAJo o rS p er a Property Description 9-DIGIT PARCEL NUMBER (from Property Tax State),ent): PROPERTY ADDRESS: J/ .5C-h lG(Y�Z- �!LC:IA//0rcitet,h,c 9 g 3 S D a /.q 0 .37 Office Use Only 4 • • BLD15-00037 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00037 Received Date: 2/10/2015 SITE ADDRESS: 511 SCHWARTZ RD NORDLAND, 98358 APPLICANT: CHARLES HARTZELL PHONE: 18304 26th DR SE BOTHELL WA 98012 SUBDIVISION: Block: Lot: PARCEL NUMBER: 021291037 Section: 29 Township: 30 N Range: 1E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW BUILDING PERMIT FORA 1980 MANUFACTURED HOME SEP14-00093 TYPE OF WORK RES MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PEERLESS SETBACK: VALUATION 20,000.00 YEAR: 1980 LABOR& INDUSTRIES APPROVAL? SIZE: 70X28 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: 05783 BEDROOMS: BATHROOMS: o Exist: 0 Exist: 0 cos1 l�( Prop: 2 Prop: 2 t Total: 2 Total: 2 CM(I:C(-4 Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $546.00 SRE 02/10/15 154110 State Building Code $4.50 SRE 02/10/15 154110 Potable Water Application $68.00 SRE 02/10/15 154110 Total: $618.50 \\tirlomm4\rlato1fnrmc\C RI n n.... nn..f.