HomeMy WebLinkAboutBLD2004-00154 BLD04-00154
UILDING PERMIT APPLIC ON Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00154 Received Date: 3/11/2004
SITE ADDRESS: 960 DUCKABUSH RD
BRINNON, 98320
OWNER: ROCHELLE F PERLMAN PHONE:
850 AMSTERDAM AVE
NEW YORK CITY NY 100255170
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 502171007 Section: 17 Township: 25 N Range: 02 W
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 DESCRIPTIOF NO NO MLA REQ'D -ABOVE GROUND 250 GALLON PROPANE TANK
REPLACEMENT
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 $48.00 CJZ 03/11/04 64069
Total: $48.00
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MAR-10-2004 WED 04:42PM ID:Cene Harvest States Pr—
• •
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 #: BLD04-00154 Received Date 3/11/2004
SITE ADDRESS: 960 DUCKABUSH RD Issue Date 3/11/2004
BRINNON, 98320
APPLICANT: ROCHELLE F PERLMAN PHONE:
850 AMSTERDAM AVE
NEW YORK CITY NY 100255170
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 502171007 Section: 17 Township: 25N Range: 02W
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, ROCHELLE F PERLMAN PHONE:
if different: 850 AMSTERDAM AVE
NEW YORK CITY NY 100255170
PROJECT DESCRIPTION: NO NO MLA REQ'D -ABOVE GROUND 250 GALLON PROPANE
TANK REPLACEMENT
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 03/11/2005.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance: ir— `j ? bs�
[ ] FinalApproval: 7. 7
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 COMMUNI VELOPMENT,621 SHERIDAN ST PORT TOWN WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION Ski4P ouT--
MARK ALL ITEMS BELOW THAT PERTAIN TO THIS INSTALLATION
Underground PROPANE TANK* Above Ground PROPANE TANK* SIZE OF PROPANE TANK J°
HEAT STOVE HOT WATER TANK WOODSTOVE FIREPLACE INSERT PELLET STOVE
COOKING STOVE OTHER(Please Specify)
Is this appliance (woodstove, htg stove, hot water tank,furnace, etc.) to be installed in a Manufactured/Mobile
Home?
YES NO
SITE ADDRESS(911#/Road Name):
1.O 0(A KA(OS l ( b
6(1- A N NO \) ZIP
9 DIGIT PARCEL ID NUMBER 362. —1 7 ( i 4 0
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range WM
APPLICANT Re. 41 11" De4 PHONE v✓ 9
MAILING ADDRESS Cr60 bUC4'G ✓b1S 43
t N IJ o Iv ZIP
PROPERTY OWNER s' S/4 M- PHONE
MAILING ADDRESS
' c ZIP
CONTRACTOR C. 1-1 + J PHONE 73 L,11S g S
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 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 licant's pro or str ture shall be requested nd shall occur during regular business hours.
APPLICANTS SIGNATURE DATE3
/ ( /
FOR OFFICE USE ONLY / �,
BASE FEE $48.00 RECEIPT# (0/ de9
CONSISTENCY REVIEW $24.00 CASH/CK# A5.�' 1
TOTAL DATE .8 / i(
Propane Tank applications require additional information to be submitted. OVER
Please contact our office at 360-379-4450 if the back of this application is blank.
G:\PermitCenter\FORMS\BLDG FORMS\install-revised 01-26-04.DOC