HomeMy WebLinkAboutBLD2004-00091 °BUILDING PERMIT APPLICI ON BL v
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00091 Received Date: 2/17/2004
SITE ADDRESS: 171 BRINNON LN
BRINNON, 98320
OWNER: DANIEL M ACKERMAN PHONE:
KATHERINE C ACKERMAN
PO BOX 149
BRINNON WA 983200149
SUBDIVISION: CARROLL'S HOOD CANAL VIEW EST Block: Lot:
PARCEL NUMBER: 941700203 Section: 2 Township: 25 N Range: 02 W
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 DESCRIPTIOP No MLA REQ"D / 120 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
Permit $48.00 CJZ 02/17/04 62570
Total: $48.00
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 #: BLD04-00091 Received Date 2/17/2004
SITE ADDRESS: 171 BRINNON LN Issue Date 2/17/2004
BRINNON, 98320
APPLICANT: DANIEL M ACKERMAN PHONE:
KATHERINE C ACKERMAN
PO BOX 149
BRINNON WA 983200149
SUBDIVISION: CARROLL'S HOOD CANAL VIEW EST Block: Lot:
PARCEL NUMBER: 941700203 Section: 2 Township: 25N Range: 02W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*0770P Expires 11/17/2004
OWNER, DANIEL M ACKERMAN PHONE:
if different: KATHERINE C ACKERMAN
PO BOX 149
BRINNON WA 983200149
PROJECT DESCRIPTION: No MLA REQ"D/ 120 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 02/17/2005.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance:
FinalApproval: ct_
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
SITE VISIT REPORP
JOB K/-""7T/4'1 / C -co...pi-49/V/ DATE �..2 /
ADDRESS )'7/ ,b'/.?i ` �,/v.7J �-��� BY
/A/•vUiilj_j.vw,li4 PHONE 7 V --4O
Draw a simple plot plan: include property s and proximity to lines, tanks, wells, driveway
shrubs & trees, exhaust vents, air intake, combustible sources, relevant windows and doors.
Clallam County, include septic. House — Mobile Home _ Commercial _ fe(/n
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Description: /V E f l� ?` "if/ %211 cr> 'i' e 4-'4
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JEFFERSON COUNTY COMMUNITY DEVELOPMENT.621 SHERIDAN ST,PORT TOWNSEND WA 98368 PH: (360)379-4450
` TALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO/THIS INSTALLATION
/Above PROPANE TANK* Above Ground PROPANE TANK* SIZE OF PROPANE TANK /2-0 je.
HEAT STOVE HOT WATER TANK WOODSTOVE FIREPLACE INSERT k' ETI (( i t,,' I� im
COOKING STOVE OTHER(Please Specify) ill - I
_. 'i
Is this appliance(woodstove, htg stove, hot water tank,furnace, etc.)to be installed in a M �tactt, Mibpe
Home? i
YES NO I L
SITE ADDRESS(911#/Road Name):
( � ��'/YJ�O� �h , ;APT.OFC� ri�y�_;JE —..,i
6fivIn or?r (,d4- ZIP q 6 320
9 DIGIT PARCEL ID NUMBER q"/ 7 00 a 0 %�
Legal Description: ` I
Subdivision Name r r a (l s i Gt Ca-pi i V/w.g.w 1 Block
Lot(s) e:71 ^S
Section Township North, Range WM
APPLICANT Ka a Gke r m
p PHONE
MAILING ADDRESS I D U)z 1 z/1
rJ [► �G` ZIP 0 ��
PROPERTY OWNER Ind / ./� �,..r- PHONE
MAILING ADDRESS Po U / Y9
'"2 `.c1- IJL ZIP 9 132"U
/
CONTRACTOR c- /�
C - S�..'�`4- f' J0a PHONE 38S$ 797
MAILING ADDRESS )085 3 Kko(9-7 Or-
Pi 144--2-L ...4 L )- ZIP f F_1J 7
STATE LICENSE# c_Sevy, s Jc/P -0 7 7Q P EXP.DATE ///O 74
FEDERAL I.D.# q/- I O 7'/ e,S_ I�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 attorneys 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 Co p 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 property .tructure shall be requested and shall occur during regular business hours.
APPL ICANT l/ UUS SIGNATURE LYr•�� "� DATE 2/ /1./ O car
r
FOR OFFICE USE ONLY
BASE FEE $48.00 RECEIPT# La 5 10
CONSISTENCY REVIEW $24.00 CASH/CK# q 1 l2
TOTAL 4 &O r�
l a - - DATE a, 11 /a00.i.
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 . . +
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 01-26-04.DOC