HomeMy WebLinkAboutBLD2012-00411 IIK
UILDING PERMIT APPLICASN Review00411
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD12-00411 Received Date: 12/26/2012
SITE ADDRESS: 110 CRESTVIEW DR
PORT LUDLOW, 98365
OWNER: SHEILA TWOHEY PHONE: 360-437-7655
110 CRESTVIEW DR
PORT LUDLOW WA 98365-9200
TEAL LAKE VILLAGE
SUBDIVISION: Block: Lot: 1
PARCEL NUMBER: 998700001 Section: 21 Township: 28 N Range: 01 E
CONTRACTOR: AIR FLO HEATING COMPANY INC PHONE: 360-683-3901
221 W CEDAR
SEQUIM WA 98382
Contractor's License AIRFLI*206DG Expires 4/25/2014
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION HEAT PUMP REPLACEMENT
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP MEC MAIN:
VALUATION 9,922.00 ADD'L: HEAT TYPE:
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $222.00 LYK 12/26/12 139841 � VE
Total: $222.00 C 1n 1G12
Jefferson DE County Planning;
& Bu°Idmp Department
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0,goN cp& JEFFERS,COUNTY •
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
�y 360/379-4450 • 360/379-4451 Fax
os, ��0 www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: nO MLA
LA
Project Description(indude separate sheets as necessary):
I-WC IN KIND rt�a'u�c M t�-r c.r N t i P Ki) S"(STEN\
Tax Parcel Number: CA� V 1 OCOC) Property Size: (acres/square feet)
Site Address and/or Directions to Property:
ll� CktiST IC W ` DPI, 1 ��T LAM 1-0
Property Owner(s)of Record: Sne%Va Two h2y
Telephone: �"13�i - ]lP 55 Fax: / email:
Mailing Address: 11O C"e h)l€ Dr I port- UUI.dx..Q).-.1 Net 4 31sc
Applicant/Agent(if different from owner): At r F(.c)
Telephone: lM0•'t.PIPj-,3010I Fax: (.a.Yb-- J°t 1 l email: ell(.neat kbhe&.tLno+
Mailing Address:
What kind of Permit?(Check each box that applies
DBuilding ❑Critical Areas Stewardship Plan
❑ Demolition Permit 0 Variance(Minor,Major or-'__ ••.. - Economic Use)
❑Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a),C(d);,,o
r (� �7
❑ Manufactured Home 0 Modular ❑ Discretionary"D"or Unnamed-bs aiii..4id(
❑ Commercial" 0 Special Use(Essential Publicv-.�._.�
❑ Change of Use 0 Boundary Line Adjustment
❑ Address ❑Road Approach ❑Short Plat**
❑ Home Business D Cottage Industry 0 Binding Site Plan** %012
0 Propane ❑Long Plat**
❑ Sign 0 Planned Rural Residential Devellran Amen n . **
❑Allowed"Yes"Use Consistency Analysis ❑Plat Vacation/Alteration** 'r'?ct N COUNTY
er
ram
ff
❑ t gement 0 Shoreline Master Prog Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Deve opm el
Site Plan
ent">---
❑Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre-Application Conference 0 Tree Vegetation Request
""Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate,A1✓Rd) 4'1{ •t'1rt to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE %-+ �c� + Date: I r D cc_. ?mil-z
By signing this application form,the owner/agent attests that the ur formation provided herein,and in any attachments,is true and correct to the best of
his,her or its knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the appli on th t he or sh(rant ,.p+.rior got '��±
Signature: a" kl, ,' W 19- Date: 11- J G C 2 0 I 1—
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
o r`tinn(e PVPO if" Dna inf�.._ ._.._�.. ..'{"........� �.. .. ,-�-- _. . _ ire, t
..Jiu..II I�.:rnaJ4i
and non-transfer�bl responsj6(Ii for adh i g to and complying th the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ••� t. Date: 1 ! p/�..0 ,_2. )
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
• BUILDER STATEMENT • .
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: +
( ) rI C -`] V{
MAILING ADDRESS: EMAIL: I
-'i
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER 1 6 2012 i
ARCHITECT/ENGINEER: PHONE ( U U. FAX:( ) j
MAILING ADDRESS: EMAIL I {
Project Type: Frame Type: Bathrooms: Shored F F641ffili_CDWiTy I:
LI New ❑ Wood Existing:
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
k Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: _ ❑ Public
Total: Name of System:
If this is a Commercial Project you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
i Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove i Woodstove i Fireplace Insert I Hot Water Tank I Pellet Stove i Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage Current Proposed g ao ?, c w 1 zI 7_: .. , b1 a u
Main Floor Heated • EH Bld App Review:
2n0 Floor Heated X w;
' - Consistency Review:
Other Heated �- Base fee: f rg ,
a
Mezzanine . Additional Section:
Heated Basement 3 t Wl'- Plan Check fee:
Unheated Basement ‘ State Surcharge fee:
Other Unheated r5 Pot Water Review fee:
r
Garage/Carport t t SUBTOTAL
Decks *-• f• 911/Rd Approach fee:
Other rGfA� Qv MD —t"\-.)--Atit~ TOTAL: $(.99Q--
• Receipt Number. i'3C1 L.I
" ' Cash/Check Number J
ESTIMATED COST(REQUIRED) Date: f s" _'` s
.Fair market value of all labor and aterials foundation to finish I c
S O c e Initials:
G:\PemvtCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc