HomeMy WebLinkAboutBLD2003-00705 BUILDING PERMIT APPLICCION B RDOe 00w p705
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00705 Received Date: 11/12/2003
SITE ADDRESS: 365 TALA SHORE DR
PORT LUDLOW, 98365
OWNER: HOMER D EVANS PHONE: (360) 437-2430
MARGARET R EVANS
365 TALA SHORE DR
PORT LUDLOW WA 98365-9261
SUBDIVISION: TALA SHORES#3 Block: Lot: 53
PARCEL NUMBER: 998200350 Section: 15 Township: 28 N Range: 01 E
CONTRACTOR: CENEX SUPPLY& MARKETING PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/6/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr ABOVE GROUND PROPANE TANK
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:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
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 _
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $47.00 KAS 11/12/03 60147
Total: $47.00 APPROVED
NOV 1 2 2003
Jefferson County Planning
& Building Department
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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 #: BLD03-00705 Received Date 11/12/2003
SITE ADDRESS: 365 TALA SHORE DR Issue Date 11/12/2003
PORT LUDLOW, 98365
APPLICANT: HOMER D EVANS PHONE: (360)437-2430
MARGARET R EVANS
365 TALA SHORE DR
PORT LUDLOW WA 98365-9261 53
SUBDIVISION: TALA SHORES#3 Block: Lot:
PARCEL NUMBER: 998200350 Section: 15 Township: 28N Range: 01 E
CONTRACTOR: CENEX SUPPLY& MARKETING PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**979OZ Expires 9/6/2004
OWNER, HOMER D EVANS PHONE: (360)437-2430
if different: MARGARET R EVANS
365 TALA SHORE DR
PORT LUDLOW WA 98365-9261
PROJECT DESCRIPTION: ABOVE GROUND PROPANE TANK
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 11/12/2004.
REQUIRED INSPECTIONS:
[ ] iller ine/Appliance: .51d/7-ek Owl Lk 14�5///
/--
[ ] FinalApprov : �/� - a- -tines/ /, /O /
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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
JEFFERSON COUNTY . DEVELOPMENT,621 SHERIDA PORT TO ND WA 9 368 PR: (360) 5 `-`
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN PTO THIS` INSTALLATION
Underground PROPANE TANK* V 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 Horn
YES A. NO
SITE ADDRESS(911#/Road Name):
fo i I L.(1 D C-0 Lc) WTI ZIP (83(7 5
9 DIGIT PARCEL ID NUMBER 73 Qc a ., 0
Legal Description: �,�'w
Subdivision Name- L. 4 fcee._ Block Lot(s)
Section p Township North, Range WM
APPLICANT OAl�' 1�, 1,=:Ch.A15 PHONE 3( "473 7 )-ce 3o
MAILING ADDRESS 3( 5- 174 LA J t1e b d 1�
to KT Lt,i o L0 ). uili ZIP 7iF-34' '
PROPERTY OWNER PHONE
MAILING ADDRESS 5/��/ -111 "
ZIP /, .,,
f ),
CONTRACTOR PHONE
MAILING ADDRESS 'y} rim Q'
ZIP ,: l' �\
STATE LICENSE# EXP.Ik .0 6)
FEDERAL I.D.# `�
G
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. y 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. ,,,;C
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 nt's property or structure s e requested and shall occur during regular business hours.
APPLICANTS SIGNATURE e. t DATE l / 1 2— /
FOR OFFICE USE ONLY { 7
BASE FEE -OI L( -2'(-rZ.% RECEIPT# G t/� / V 1
CONSISTENCY REVIEW 3 -3 L CASH/CK# 1-.,,dj
TOTAL -.?C_ • --L DATE // / A/ C-V
Propane Tank applications require additional information to be submitted.
Please contact our office at 360-379-4450 if the back of this application is blank. OVER 4 4 5
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G:\PermitCenter\FORMS\BLDG FORMS\ install-revised 10-30-03.DOC