HomeMy WebLinkAboutBLD2000-00577 BUILDING PERMIT APPLICATION ';
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD00-00577 Received Date: 9/6/2000
SITE ADDRESS: 923 CARL JOHNSON RD
QUILCENE, 98376
APPLICANT: ANNE M BASELT PHONE: (360)377-8824
808 HAYWARD AVE
BREMERTON WA 983104891
SUBDIVISION: Block: Lot: T 18
PARCEL NUMBER: 701043011 Section: 04 Township: 27 N Range: 01 W
CONTRACTOR: OWNER PHONE
ARCHITECT!
ENGINEER :
PROJECT DESCRIPTION: SINGLE FAMILY RESIDENCE
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 576
VALUATION 31,882.00 ADD'L: HEAT TYPE: EEE
CODE EDITION: 1997 HEAT BASE: HEAT TYPE: PRO
OCCUPANCY: R-3 UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK: 200
BANK HEIGHT: 10
SEWAGE DISPOSAL: CON
WATER SYSTEM: PWELL PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: 1 Prop: 1 Seismic Streams
Total: 1 Total: 1 Flood Way Flood Plane
F&W Landslide
Routing Date: 9 ` ,133 Shoreline Aquifer
Forest: Commercial Rural
—Pr ximity - flat Uond dons
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $461.95 MAM 09/06/00 34143
Plan Check $138.59 MAM 09/06/00 34143
State Building Code $4.50 MAM 09/06/00 34143
Potable Water Application $30.00 MAM 09/06/00 34143
Total: $635.04
is\F_BLD_App_Bid.rpt 10/29/99
r 4
Jefferson County 6epartment of Conmudty Development
y,14 cot 621 Sheridan Street,Port Townsend WA [3601378-4450
0�S �.. Apt, 0o�Q�0 0�
Project Description: /VQCl1 LC;t/S:7` . �5lI1 /E ,071-A e, % {�< �' tC
Building Type: ject Type: I Frame Type:
1.,( YP
Y`Single Family ,New Wood
❑ Garage Attached/Detached ❑ Addition ❑ Steel
❑ Modular ❑ Alteration/Remodel ❑ Concrete
❑ Commercial ❑ Repair ❑ Masonry
❑ Multi-family/#of Units ❑ Demolition ❑ Other.
❑ Industrial
❑ Other.
Bedrooms: 1 Bathrooms: ` I Type of Sewage Disposal: Type of Heat:
Goose one:
Existing: C) Existing ® ❑ Sewer ❑Community Systems, ?(Electricity ❑ Oil
Proposed: i Proposed: ! Individual System (7 U, tv ❑ S Woodstove 'Propane
Total: Total: iff not sewer,fill out the following: ❑ Heat Pump
Conventional ❑ Alternative ❑ Other
ermit# SEP 9 'C `r
1 Water Supply:
�( Private well ❑ Two Party W ❑ Public Name of water system:
Square Footage: For Office Use Only
Main Floors UBC OCCUPANCY GROUP
2ND Floor Base fee 9' t` 5'
3rd 5Floor Plan.Check fee \ , 9
Htd Basement State Surcharge-fee
Unhtd Basement Subtotal 6 n v 0
Garage/Carport Pot Water Review fee C'- C 0
Decks 911/Rd Approach fee
Commercial TOTAL 6 3`--',
Industrial Receipt # '
471174/
Other Cash/Check# -
Total Valuation: !,' Initials
Or Date - 0 0
Estimated Cost:
If within 200' of the Shoreline,
Distance to Bank or Ordinary High Water M a.COft.Bank Height 10 ft.
By signing the application form,the applicant/owner attests that a information provided herein is true and correct to the best of their knowledge. Any material falsehood or any
omisss"on of a material fact made by the applicant/owner with res to this application packet may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson Co ry against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue
against Jefferson County as a result of or in consequence of the gran g of this permit.
I further agree to provide access and right of entry to Jefferson County and it's employees,representatives or agents for the purpose of application review and any required later inspections.
Access and right of entry to the applicant's pro erty or structure shall be requested and shall occur during regular business hours.
Signature:1 ( /22
Date: / �"
Jefferson County Department of Community Development
N c 621 Sheridan Street,Port Townsend WA 98368 (360) 379-4450
\ ' Universal Plot Plan
Fill in the following blanks as completely as possible:
Project Description:
QIUE 'enPOCM A/ me Akio COY1s7'sa 12
9 Digit Parcel Identification Number (from your tax statement):
?01 044 3 o tl
Site Address Car.--( jo({NsoN Rcj �v l ICene,
911#: (71 a, 3 Road Name: Zip Code: (7,?' 3 9
Legal Description
Subdivision Name: 044 - a 7 0 I W Block: Lot(s):
Section: Township: ?N Range: / W
Parcel Size (acres or square footage): / / 7a
Property Owner: 47,ti , 0a(2°
Mailing Address: 620.9
l/ �GU D A- _, i3 M ' `�7fx --1 WA 9?-3/0
Applicant/Occupant: `Z Phone:
(if different from owner)
Mailing Address:
Authorized Rep: Phone:
Mailing Address:
General Contractor:
Or Manufactured Home Install � \ ) � cr Phone:
Mailing Address:
Contractor's State License Number: Expiration Date:
Septic Designer: J( `0 r er Phone: 766— 3 Z/4
Mailing Address:
Architect:/Engineer: Phone:
Mailing Address:
Loan Lender/General Phone:
Contractor's Bond Holden
Mailing Address:
FOR OFFICE USE ONLY
Fire District: Planning Area: School District: Zone:
1/00 H:\home\pincntr\forms\universal plot plan
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