HomeMy WebLinkAboutBLD2003-00646 Al/
PROPANE/PELLET/WOOD STOVE & TANK INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD03-00646 Received Date 10/13/2003
SITE ADDRESS: 1090 WEST VALLEY RD Issue Date 10/13/2003
CHIMACUM, 98325
APPLICANT: JACK D GRAY PHONE:
DALE J KLEIN JTWROS
PO BOX 1789
PORT TOWNSEND WA 98368 1
SUBDIVISION: HALL SHORT PLAT Block: Lot:
PARCEL NUMBER: 901154013 Section: 15 Township: 29N Range: 01W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 9/26/2004
OWNER, JACK D GRAY PHONE:
if different: DALE J KLEIN JTWROS
PO BOX 1789
PORT TOWNSEND WA 98368
PROJECT DESCRIPTION: PROPANE TANK AND HEAT STOVE INSTALLATION
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 10/13/2004.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance: •
/� f/ del-/4 4 ' iD/Z /D3 �T
[ ] FinalApproval: ,e2f` or Øi 10/Z030
l
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
I:\F_BLD_Permit_Propane.rpt 10/29/19
� BLD03-00646
UILDING PERMIT APPLICATTvN Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00646 Received Date: 10/13/2003
SITE ADDRESS: 1090 WEST VALLEY RD
CHIMACUM, 98325
OWNER: JACK D GRAY PHONE:
DALE J KLEIN JTWROS
PO BOX 1789
PORT TOWNSEND WA 98368
SUBDIVISION: HALL SHORT PLAT Block: Lot: 1
PARCEL NUMBER: 901154013 Section: 15 Township: 29 N Range: 01 W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 9/26/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOD PROPANE TANK AND HEAT STOVE INSTALLATION
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 1997 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Floodplain
Routing Date: F&W Landslide
O� l3 ToP
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 PRB 10/13/03 60262
Total: $47.00
JEFFERSON COUNTY COMMUNITSVELOPMENT,621 SHERIDAN ST.PORT TOWNS NA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN
�TOTHIS INSTALLATION
Underground PROPANE TANK* Above Ground PROPANE TANK HEAT STOVE HOT WATER TANK
WOODSTOVE FIREPLACE INSERT PELLET STOVE COOKING STOVE
OTHER(Please Specify)
Is this appliance(htg stove, hot water tank,furnace,etc.)to be installed in a Manufactured/Mobile Home?
YES Y- NO
SITE ADDRESS(911#/Road Name):
10 90 k1is V9 II e7 J2//
( Aim 4CQvlm ZIP 9 �53as
9 DIGIT PARCEL ID NUMBER c /- o 13
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range WM
APPLICANT Mountain Prn7r, PHONE 3� 6 '%3
265 Chimacum Rd.
MAILING ADDRESS Port Hadlock, WA 9833
/ ZIP
PROPERTY OWNER ,TqC} U-YQ y PHONE 7 .01- 2 y,S a-
MAILING ADDRESS P, 0 , Sox f 2 89
Port TO(-v/7 s/ 7rIc / ZIP �� 6 /
CONTRACTOR Mountain Prnparia PHONE 3�5.5- 6 5<g.3
265 Chlmacum Rd.
MAILING ADDRESS Port Hadlock,WA 98339
ZIP
STATE LICENSE# 7)1 014 N ) l Z q$30/� EXP.DATE 9 -016 -o 5/
FEDERAL I.D.#
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or
any omission of a material fact made by the applicant/owner 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 it's employees,representatives or agents for the purpose of application review and any required later
inspections. Access and right of entry to the appli is property or structure shall be requested and shall occur during regular business hours.
APPLICANTS SIGNATURE DATE ) / 13 / 6)3
�� ^ FOR OFFICE USE ONLY
BASE FEE +,.� RECEIPT# 6C2 Z
CONSISTENCY REVIEW .. CASH/CK# SC/ `1"
TOTAL t- -co DATE (C)/(3 / D
*Underground Propane Tank applications require additional information to be submitted. 0 V E R 10.
Please contact our office at 360-379-4450 if the back of this application is blank.
g:\permitcenter`forms\bldg forms\install-revised 10-23-02.doc