HomeMy WebLinkAboutBLD2004-00035 • •
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 #: BLD04-00035 Received Date 1/22/2004
SITE ADDRESS: 462 CLEVELAND ST Issue Date 1/22/2004
PORT HADLOCK, 98339
APPLICANT: NORA NELL HOLM PHONE:
12741 CASE ROAD SW
OLYMPIA WA 98512
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 921063005 Section: 6 Township: 29N 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, NORA NELL HOLM PHONE:
if different: 12741 CASE ROAD SW
OLYMPIA WA 98512
PROJECT DESCRIPTION: ABOVE GROUND PROPANE TANK/NO MLA REQ'D
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 01/22/2005.
REQUIRED INSPECTIONS:
[ ] Line/Appliance: ek 4/05-
41
[ ] FinalApproval: OA' -car 3//05 "1,44
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 10/29/19f
JEFFERSON COUNTY COMMUDEVELOPMENT,621 SHERIDAN ST,PORT TOW•D WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERT IN 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):
L 2-• Cleve/land and : -
1 L i (. F ZIP .341
9 DIGIT PARCEL ID NUMBER C2 I` Oer" - SOS
Legal Description:
Subdivision Name Block Lot(s)
Section ( /+� Township North, Range L WM
APPLICANT ' o t > �^"'QM r✓t✓t J PHONE 3G(:)-15M-c f OO
MAILING ADDRESS /12?Lf I Q (�1 ,IE (20 .`": e -^�
4..t/��I M` 11`1 of ZIP GIPr'S✓)t [—
PROPERTY OWNER t PHONE
MAILING ADDRESS ''St\Ms_
ZIP
CONTRACTOR Cy a 1 1 .S 7. PHONE
MAILING ADDRESS
�y l ZIP
STATE LICENSE# .-•� OtFits. 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 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 th plicant's pro y or structure shall b equest an shalleitrring regul business hours. = C
APPLICANTS SIGNATURE I OP DATE / G 1 / ul
FOR OFF E USE ONLY
BASE FEE $4.00 RECEIPT# 3 1
CONSISTENCY REVIEW °O
�4 CASH/CK# vA5
r
TOTAL N. DATE / / e2-1--/ 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 4
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 10-30-03.DOC
•
BUILDING PERMIT APPLICJON BLD04 000e35
view Typ
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00035 Received Date: 1/22/2004
SITE ADDRESS: 462 CLEVELAND ST
PORT HADLOCK, 98339
OWNER: NORA NELL HOLM PHONE:
12741 CASE ROAD SW
OLYMPIA WA 98512
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 921063005 Section: 6 Township: 29 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 DESCRIPTIOr ABOVE GROUND PROPANE TANK/ NO MLA REQ'D
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 $48.00 CJZ 01/22/04 62391
Total: $48.00
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