HomeMy WebLinkAboutBLD2003-00779 • •
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 #: BLD03-00779 Received Date 12/12/2003
SITE ADDRESS: 63 ROBIN LN Issue Date 12/12/2003
PORT LUDLOW, 98365
APPLICANT: FRANK D MILLER PHONE:
SHERRY A MILLER
63 ROBINS LN
PORT LUDLOW WA 98365 13
SUBDIVISION: BRIDGEHAVEN DIV 8 Block: Lot:
PARCEL NUMBER: 935900013 Section: 8 Township: 27N Range: 01 E
CONTRACTOR: C H S PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 09/06/2004
OWNER, FRANK D MILLER PHONE:
if different: SHERRY A MILLER
63 ROBINS LN
PORT LUDLOW WA 98365
PROJECT DESCRIPTION: NO MLA REQ'D -ABOVE GROUND 250 GALLON 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 12/12/2004.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance:
[ ] FinalApproval: C. C -OL
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
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',BUILDING PERMIT APPLIC . ON BLD03-00779
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00779 Received Date: 12/12/2003
SITE ADDRESS: 63 ROBIN LN
PORT LUDLOW, 98365
OWNER: FRANK D MILLER PHONE:
SHERRY A MILLER
63 ROBINS LN
PORT LUDLOW WA 98365
SUBDIVISION: BRIDGEHAVEN DIV 8 Block: Lot: 13
PARCEL NUMBER: 935900013 Section: 8 Township: 27 N Range: 01 E
CONTRACTOR: C H S PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 09/06/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP NO MLA REQ'D -ABOVE GROUND 250 GALLON 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:
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
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 CJZ 12/12/03 60577
Total: $47.00
JEFFERSON COUNTY COMMU•DEVELOPMENT,621 SHERIDAN ST,PORT TOW•D WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO THIS INSTALLATION
„ZS 05�1/ah
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 Home?
YES NO
SITE ADDRESS(911#/Road Name):
(3 ()o.L h La ,Lie
L Q67 1 lobo, 1,4)A ZIP
9 DIGIT PARCEL ID NUMBER -f 3 -1 00 - Q 1_j
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range WM
APPL T pp !�. !C lid rry /k a J 1 d- PHONE 3 rl' :c-Z)II
MA LING ADDRESS L
(�
r d- 1,L, c) 16)w, w/4 ZIP %
PROPER WNER PHONE
MAILING ADDRESS
ZIP
CONTRACTOR Cp y X PHONE
MAILING ADDRESS
ZIP
STATE LICENSE# EXP.DATE
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 ent to erso o my and ployees,representatives or agents for the purpose of application review and any required later
inspections. Access and right of entry to the a s pro.I. , t. , tructu Mr. be requested and s I occur rhg regular business hours.
APPLICANTS SIGNATURE T fit DATE t'oZ I ) / (j
FOR OFFICL USE ONLY /� _ �7
BASE FEE $47.00 RECEIPT# C—L-�76 5 (
CONSISTENCY REVIEW a3 5° CASH/CK# ` ' -11
TOTAL —0050— DATE / a/ /&003
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 5 4 4
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 10-30-03.DOC