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Home My WebLink AboutBLD2003-00794 • I 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 #: BLD03-00794 Received Date 12/22/2003 SITE ADDRESS: 150 JEFFERSON ST Issue Date 12/22/2003 PORT LUDLOW, 98365 APPLICANT: DAVID H SIEMSSEN PHONE: ALICE DL SIEMSSEN 150 JEFFERSON AVE PORT LUDLOW WA 98365 84 SUBDIVISION: PORT LUDLOW NO 2 AREA 3 Block: Lot: PARCEL NUMBER: 990600384 Section: 9 Township: 28N Range: 01 E CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883 265 CHIMACUM RD PORT HADLOCK WA 98339 Contractor's License MOUNTPI98306 Expires 09/26/2004 OWNER, DAVID H SIEMSSEN PHONE: if different: ALICE DL SIEMSSEN 150 JEFFERSON AVE PORT LUDLOW WA 98365 PROJECT DESCRIPTION: NO MLA REQ'D -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 12/22/2004. REQUIRED INSPECTIONS: [ ] an i /App /AA) PPLi�.J�L�S /2-/.3/A3 [ ] malApprov I: J2/ "i 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 is\F_BLD_Permit_Propane.rpt 10/29/195 BLD03-00794 UILDING PERMIT APPLIC N Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD03-00794 Received Date: 12/22/2003 SITE ADDRESS: 150 JEFFERSON ST PORT LUDLOW, 98365 OWNER: DAVID H SIEMSSEN PHONE: ALICE DL SIEMSSEN 150 JEFFERSON AVE PORT LUDLOW WA 98365 SUBDIVISION: PORT LUDLOW NO 2 AREA 3 Block: Lot: 84 PARCEL NUMBER: 990600384 Section: 9 Township: 28 N Range: 01 E CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883 265 CHIMACUM RD PORT HADLOCK WA 98339 Contractor's License MOUNTP198306 Expires 09/26/2004 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NO MLA REQ'D -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: 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 12/22/03 60536 Total: $47.00 JEFFERSON COUNTY COMMUNIEVELOPMENT,621 SHERIDAN ST,PORT TOWN WA 98368 PH: (360)379-4450 INSTALLATION PERMIT APPLICATION MARK ALL ITEMS BELOW THAT PERTAIN TO THIS 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 NO SITE ADDRESS(911#/Road Name): /CO e."(-rcroi) 2- )Gt/ , W" ZIP 9 DIGIT PARCEL ID NUMBER 9 9O 600 3.g9 Legal Description: Subdivision Name Block Lot(s) Section Township North, Range WM APPLICANT Mountain Proppnn PHONE 3 SS- 6 S '3 265 Chimacum Rd. MAILING ADDRESS Port Hadlock,WA 98339 ` ZIP PROPERTY OWNER D c v i 6� $�JI 'n s en PHONE 1$ 7 -" O,3 f y MAILING ADDRESS ISO TP-Pre r t n 4 ve t� Port 0.14dI0, �/ , �'¢ ZIP 7 03 CONTRACTOR Mountain Propane PHONE 3 ASS- 6g g 3 265 Chimacum Rd. MAILING ADDRESS Port 14adiock,WA 98339 ZIP STATE LICENSE# /n O kl/j!/'T'P z- 9`03 06 EXP.DATE 9 016 --0 9 FEDERAL I.D.# I` o�OS86 SS 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 plicant's property or structure shall be requested and shall occur during regular business hours. APPLICANT'S SIGNATURE DATE �.0)--/ 2 9 / O BASE FEE ��fcoFOR OFFICE USE ONLY RECEIPT# - I�( 0 S J 6 , 7 CONSISTENCY REVIEW 3 S° CASH/CK# ` Co TOTAL 7 0 • DATE 1 / I q/ 03 *Underground Propane Tank applications require additional information to be submitted. 0 V E R 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 DEC 1 9 2003 UndergrounPropane Tank Applicationeequirements When applying for a permit to install an underground propane tank you must submit the following: 1. Site plan showing all of the buildings, all property lines, tank location, distances from the tank to all property lines and buildings, septic system components including the reserve area. 2. Tank must be installed per NLPGA#401-87. Copies are available in our office for a fee of $.90. 3. Plans are required. You must submit a section view and a plan view with all dimensions. 4. An additional fee of$23.50 for Consistency Review is required. The total amount due at time of application is $70.50. I\/ S t ?co toPr .LIOp I a cue/ 0 i______ 2 It / `f 0r 10 w4rsor)v,IIr e 133O