HomeMy WebLinkAboutBLD2004-00058 BUILDING PERMIT APPLIC `ION BLD04 0005 8
w Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00058 Received Date: 2/2/2004
SITE ADDRESS: 395 FORT GATE RD
NORDLAND, 98358
OWNER: LEONARD V MERMOD JR PHONE:
REBECCA J MERMOD
395 FORT GATE RD
NORDLAND WA 983589516
SUBDIVISION: INGMAN-NUTSFORD SHORT PLAT Block: Lot: 3
PARCEL NUMBER: 021202049 Section: 20 Township: 30 N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr PROPANE TANK INSTALLATION
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION
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
1
- ,21(} 91&
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 PRB 02/02/04 62534
Total: $47.00
• •
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 #: BLD04-00058 Received Date 2/2/2004
SITE ADDRESS: 395 FORT GATE RD Issue Date 2/2/2004
NORDLAND, 98358
APPLICANT: LEONARD V MERMOD JR PHONE:
REBECCA J MERMOD
395 FORT GATE RD
NORDLAND WA 983589516 3
SUBDIVISION: INGMAN-NUTSFORD SHORT PLAT Block: Lot:
PARCEL NUMBER: 021202049 Section: 20 Township: 30N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2004
OWNER, LEONARD V MERMOD JR PHONE:
if different: REBECCA J MERMOD
395 FORT GATE RD
NORDLAND WA 983589516
PROJECT DESCRIPTION: PROPANE TANK 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 2/2/2005.
REQUIRED INSPECTIONS:
/ 3/[ Tank/ ne/Appliance: A le c A Ae it4E 4ene 0 4
fr< FinalApproval: C 0/4/0.,
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 COMMIS,DEVELOPMENT,621 SHERIDAN ST,PORT TOWD WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO THIS INSTALLATION
G-/A
Underground PROPANE TANK* 1.7Above 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 9 S Fsr r 6- Pr E P.r0
" cry- 0 L�1 p Cj r ZIP ( U S E3
9 DIGIT PARCEL ID NUMBER 0�- I a . 0 2-0 14
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range WM
APPLICANT GCLC c-r �►'"�� PHONE 37 1- 188/
MAILING ADDRESS
ZIP
•
PROPERTY OWNER -Qt-e�, � PHONE
MAILING ADDRESS FEB 2
2004
ZIP
CONTRACTOR 3 et A-� PHONE
MAILING ADDRESS (qO , 112- O C
F -S-f2- 1 e.4l ()c. , ZIP /
STATE LICENSE# S(-4.h-s (4P .fE c 7 i/7 Q P EXP.DATE 1 O LI
FEDERAL I.D.# L i / 0 7 4 d'J 7 ((/
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 applicant's prope y or structure shall be requested and shall occur during regular business hours.
APPLICANTS SIGNATURE DATE I/ l O y
FOR OFFICE USE ONLY 1,
BASE FEE $47.00 RECEIPT#
CONSISTENCY REVIEW 23 -50 CASH/CK# c g
TOTAL 10 •SU DATE Z / 2_1 o L-
*
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
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 10-30-03.DOC
All Prone Tank Application Recrements -
When applying for a permit to install a propane tank you must submit the following:
1. Site plan showing all of the buildings, all property lines, tank location, distances from the
propane tank to all property lines and buildings, septic system components including the
reserve area. Indicate the size of the tank and whether or not it is above ground or below
ground.
2. An additional fee of$23.50 for Consistency Review is required. The total amount due at time
of application is $70.50.
hi,J 6-ro c.un.S. 5 0 0 �-``''. . ( °"`-Ire k--c i r f
'Q-2 1 a 1 et.' 5 a sb 6-`.. Fe-►1-( Pr ._i_c,„_,L)
I
i
10
_ G
S etp r-/ am `
FEB - 22004 '
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 10-30-03.DOC