HomeMy WebLinkAboutPermit File 1911 10th Street Engineering and Development Services 49 .q
• G11.Yrr Off, PO Box 547 Anacortes WA 98221 �'
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TN 360.293 1920 FAX 360.293 1938 Z
I. EMAIL engineering@cityofanacortes org
y n RIGHT—OF—WAY PERMIT APPLICATION 6 0
�r �' RCW 19.122 Underground Utilities ,�. tQ
`9CORD CALL BEFORE YOU DIG -;(800)424-5555 '4.P•vi.r- 1 dI I
Applicant shall submit application 5 days prior to start of work and application shall include: �9(
) Payment of assessed fee
l (2) Drawing illustrating proposed work and its location. See checklist on
Page 2 of 2.
t -1 1Liability insurance CG 2026 or similar. City named as additional insured. Minimum$1,000,000 each
occurrence,$2,000,000 general aggregate and$2,000,000 products-completed operations aggregate limit.
4 -12frProof of both state and city business licenses
Le— 5j"Performance Bond—Construction cost x 150%before work begins -
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Site Address: City Approved Exemption r Yes [_ No
\ 1 1 � '�"C` -(-c c_1-- EDENASSIGNED PER�'`NUMBER: ���I
Parcel No. 4 6—7 ( •
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Owner Information (Required) Contractor Information (Required)
Name , .3 zA.1,-1L v,__Q , Name svrctrldi-,-g41- f CetiJC. ✓--N_
Address Address -/ -
City A _ l City /
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/ Phone Phone
' 60 1 --OYU `-/ 36 (-) /4I vI/O
Email Email '
Address Intl 5. C.,„"-(A-/C,, , ( ;,,,,Address Sc-t.,vv "L._
Work Includes(check all that apply) ,.
Curb Cut Water Sewer S'° torrn Street Cut C Sidewalk D Phone L Other
Describe Work to be Performed: (Notification of Utility Companies is Required)
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C Approval Signal re �, Date
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By signature below Applicant concurs that the Applicant shall defend,indemnify and hold the City, its officials,em-
ployees and volunteers harmless from any and all claims,injuries,damages,losses or suits including attorney fees,
arising out of or in conn- tion with activities or operations performed by the Applicant or on the Applicant's behalf
out of issuance of• rmit,except for injurie - • damages cause by the sole negligence of the City.
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Applicant Signat 46 Date
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Final Inspection Approval Signatu' Date ;
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NON-REFUNDABLE PERMIT FEE: (To Be Completed by City)
0 Curb Cut $50.00
Street Cut $50.00
Inside Travel Way $50.00
D Outside Travel Way $20.00
❑ Sewer Inspection Fee $50.00
0 Sewer Re-Inspection Fee $25.00
TOTAL FEE ASSESSMENT $-g:),CO
A Site Plan (to scale)must be attached that include all of the following:
This checklist will aid the applicant in preparing a site plan.Permits that require installation of substantial improve-
ments may require plans drawn and designed by a licensed engineer. Please check with City staff prior to submit-
ting your application.
• Draw the plan to a standard Engineering Scale[1"=10', 1"=20"etc.]on a minimum size sheet of 8'/4 x 11
and a maximum size of 11x17.
• Include the owners name,the parcel ID number,site address, north arrow,drawing scale and date.
• Include the contractor's name,address and phone number.
• Existing Right-of-Way lines, property lines, edge of pavement,curb/gutter, sidewalks,driveways and plant-
ing strips with dimensions between each.
• Adjoining street name(s)to the reference property.
• All existing public and private utilities in the area of the proposed project(Water, Sewer, Storm, Phone,TV,
Gas and Power), dimensioned to the edge of pavement,curb/gutter,sidewalk,driveways,planting strips.
• It applicable show easements, critical areas such as streams,wetlands and steep slopes.
• Proposed new construction.The proposed improvements shall be shown in heavier line type than the ex-
isting information
• Dimension the proposed new construction to the edge of pavement,curb/gutter,sidewalks,driveways,
planting strips, or another identifiable site feature that will help identify the proposed improvements in the
field.
• Erosion Control Plan.
• Traffic Control Plan per current MUTCD(See standard drawings at htto://mutcd/fhwa.dot.gov). If the work
requires any lane or street closures,the City of Anacortes Public Works Inspector must be notified a mini-
mum of 48-hours prior to scheduled work for proper public notification by the City of Anacortes.
Work within the City Right-of-Way is permitted by approval of the City Engineer. All work in the right-of-way must be
bonded. The applicant and owner must use warning signs,traffic control, and barricades as necessary to ensure
public safety in the work area. The applicant and owner must restore the right-of-way to previous condition. Perma-
nent restoration may include overlays of portions of the right-of-way and restoration of landscaping which have been
disrupted by excavation work. The applicant and owner are liable for damage to public and private property.
Page 2 of 2
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Name: r'.5,P\i0HPG NELS
Add : 191i 1L!rH 21 AN4iFkA ,F3'.'211
41 $2M3, (30W - Permit Fees
* Customer #: 00?329
* Permit #: 6(D-2011-0198
43 $56 )U JOHO - Permit Fees
* Custome''' d: 60/329
* Pe:-mit #: ROW-2011-0081 _
2 JAM'S): loftd $253,08
Uheck (LV4!-MC.; PA1P $26jAi
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'ST4Y O . City of Anacortes Permit#: BLD-2011-0198
904 6th Street Issue date: 06/24/2011
P.O.Box 547
$ Expire date: 12/20/2012
'0; Anacortes, WA 98221-0547
r>;I (360) 293-1901
Job Address: 1911 10TH ST Permit Type: Single Family Alteration/Repair Permit
ANACORTES WA 98221-1419 Project:
APN: P56071
Remarks: New sliding exterior door and re-roof residence.
Owner: NELS STRANDBERG Contractor:
Address: PO BOX 319 Address:
BURLINGTON WA 98233-0319
Phone: (360)293-7431 Phone:
License#:
General Information: Fees:
Building Valuation 10000 Building Permit Fee 146.25
Plan Review Fee 52.33
State Building Code Fee 4.50
Total Calculated: 203.08
Deposits/Receipts: 0.00
Total Due: 203.08
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THIS PERMIT BECOMES NULL AND VOID IF WORK OR CONSTRUCTION AUTHORIZED IS NOT COMMENCED WITHIN 180 DAYS, OR IF} *—
CONSTRUCTION OR WORK IS SUSPENDED OR ABANDONED FOR A PERIOD OF 180 DAYS AT ANY TIME AFTER WORK IS COMMENCED. y +Y+
HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE AND CORRECT. ALL
PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED WITH WHETHER SPECIFIED HEREIN OR
NOT, THE GRANT G OF A PERMIT DOES NOT 'RESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISIONS OF ANY OTHER r+
STATE OR LO - LAW REGULATING CONST CTION OR THE PERFORMANCE OF CONSTRUCTION.
SIGNATURyOF 0 NER OR AUTAit RIZED AGENT ISSUr,m(
01 g: Residential Building Permit Application
Building Department
P.O. Box 547 Anacortes, WA 98221
Phone No.: 360-293-1901 FAX: 360.293.1938
SITE ADDRESS: iq 1( /D` —
CONTRACTOR ®Applicant PROJECT DESCRIPTION —
Name C`l I \ c V . Yl( eL`1 9 rs A e0 p �1 ei fc
Address b I
ck.}3
City/State/Zip (Z cc; ) (r
Phone->ls't` r 2`1 3-7y \FAX 3u,7 lc(fS(.(, O — eu-)
State License# A(0 02A1A_ Exp 1 L
PARCEL NUMBER ..
City of Anacortes License 1
PROPERTY OWNER El Applicant LEGAL DESCRIPTION
Name Q'1`3 aar,d.6t
Address c- C..) � ^�G�
City/State/Zip 11�V `tk-(" ) L' PROJECT VALUATION
Phone 36 0 6(1-LAUL►FAX �C�C�V U_�—
�• `� Number of Dwelling Units d
E-Mail Address ►�S � ` "7�'r`� Number of Stories ►'12 -
`"--' - Building Area:
0 Architect 0 Designer ❑Engineer 0 Applicant 1'`Floor s.f. 2"d Floor s.f.
Name 3rd Floor s.f. Basement s.f.
Address Garage s.f. Carport s.f.
City/State/Zip Deck s.f. Lot Area s.f.
Phone FAX
E-mail Address
CONTACT ❑Applicant LENDER Y I A-
LENDER INFORMATION MUST BE PROVIDED FOR PROJECTS OVER$5,000
Name I`� IN VALUATION PER RCW.
Address Name
City/State/Zip Address
Phone FAX City/State/Zip
E-mail Address Phone No.
CONTINUED ON THE BACK
Residential Mechanical Fixtures
Fuel Type
❑ Natural Gas 0 Electric 0 Wood 0 Propane Gas 0 Other
Type of Equipment Number of Type of Equipment Number of
Fixtures Fixtures
Furnace<=100K BTU Clothes Dryer
Boilers/AC/Heat Pump Gas Water Heater
Gas Outlets Gas Fireplace
Ventilation Fans Fireplace Insert
Stove,Appliance Other Units
Range Hood
Residential Plumbing Fixtures
Type of Fixture Number of Type of Fixture Number of
Fixtures Fixtures
Toilet Clothes Washer
Bathtub Electric Water Heater
Shower Utility Sink
Dishwasher Hose Bibb
Hand Sink Water Piping
Kitchen Sink w/Disposal Additional Fixtures
I HEREBY ACKNOWLEDGE IF HAVE READ THIS PERMIT APPLICANT AND STATE THE INFORMATION IS CORRECT,AND AGREE TO COMPLY
WITH ALL CITY ORDINANCES AND STATE LAWS REGULATING ACITIVIES COVERED BY THIS PERMIT APPLICATION. WITH THIS PERMIT ALL
CONTRACTORS AND SUBCONTRACTORS SHALL HAVE A CURRENT WASHINGTON STATE CONTRACTORS LICENSE AND A CITY BUSINESS
LICENSE. STOP WORK ORDERS WILL BE ISSUED ON JOB SITES WHERE CONTRACTORS/SUBCONTRACTORS ARE WORKING WITHOUT
PROPER LICENSE.
APPLICANT'S SIGNATURE DATE
•
Last Updated 11-29-05
A `
os'T Y 0 :, City of Anacortes Permit#: BLD-2003-8972
904 6th Street Issue date: 08/2712003
`+ +' P.O.Box 547 Expire date: 08/26/2004
'.4,' 0-, Anacortes, WA 98221-0547
'`,4-„Q' ck?- (360) 293-1901
Job Address: 1911 10TH ST
ANACORTES WA 98221
APN: P56071
Permit Type: Single Family Alteration/Repair Permit
Project: '
Remarks: Replace existing siding with rot.
Applicant: DANSINGBURG FRED I Owner: DANSINGBURG FRED I
Address: Address:
Phone: Phone:
Contractor:
Addressr:
Phone:
License#:
General Information: Fees: i
Building Valuation 1000 Building Permit Fee 17.50
State Building Code Fee 4.50
Total Calculated: 22.00
Deposits/Receipts: 0.00
,F Total Due: 22.00
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THIS APPLICATION IS RECEIVED BY THE BUILDING OFFICIAL UNDER THE PROVISIONS OF THE UNIFORM BUILDING CODE, AND SHALL
EXPIRE BY LIMITATION AND BECOME NULL AND VOID IF PERMIT IS NOT OBTAINED WITHIN 180 DAYS OF THIS APPLICATION. BY AFFIXING
MY SIGNATURE I HEREBY CERTIFY THAT I AM THE LEGAL OWNER OF THE PROPERTY FOR WHICH THIS APPLICATION IS ISSUED OR AN
AUTHORIZED AGENT OF THE OWNER.ALL PROVISIONS OF LAWS AND ORDINANCES GOVERNING THIS TYPE OF WORK WILL BE COMPLIED
WITH WHETHER SPECIFIED HEREIN OR NOT NCLUDING CALLS FOR INSPECTIONS.�
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Applicant Signature Issued by
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Address /9// /U di 54.
Legal Description L 7 g 7' 7 IT Ole(
Assessors Account No. 9772 -/4r'- 007- coo
Permit No. Date Description Date Finaled
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