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HomeMy WebLinkAboutBLD2004-00519 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 #: BLD04-00519 Received Date 8/10/2004 SITE ADDRESS: 60 MOCKINGBIRD LN Issue Date 8/10/2004 PORT LUDLOW, 98365 APPLICANT: NOBLE R NILSEN PHONE: LUCILE I NILSEN 60 MOCKINGBIRD LN PORT LUDLOW WA 983659759 64 SUBDIVISION: PORT LUDLOW NO. 4 Block: Lot: PARCEL NUMBER: 990500064 Section: 8 Township: 28N Range: 01 E CONTRACTOR: C H S PHONE: (360)732-4585 PO BOX 518 AUBURN WA 98071-0518 Contractor's License CHSIN**9790Z Expires 9/6/2004 OWNER, NOBLE R NILSEN PHONE: if different: LUCILE I NILSEN 60 MOCKINGBIRD LN PORT LUDLOW WA 983659759 PROJECT DESCRIPTION: PROPANE TANK AND FIREPLACE INSERT 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 8/10/2005. REQUIRED INSPECTIONS: [ ] Tank/Line/Appliance: A i017.4ii-1/Thi" � .6001 8/44/ Y ;;Ax fA9cAz. t K #470fr [ ] FinalApproval: oe Cr 4.A4,1 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 11, BUILDING PERMIT APPLATION B RD04 OOw ppe19 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00519 Received Date: 8/10/2004 SITE ADDRESS: 60 MOCKINGBIRD LN PORT LUDLOW, 98365 OWNER: NOBLE R NILSEN PHONE: LUCILE I NILSEN 60 MOCKINGBIRD LN PORT LUDLOW WA 983659759 SUBDIVISION: PORT LUDLOW NO. 4 Block: Lot: 64 PARCEL NUMBER: 990500064 Section: 8 Township: 28 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 9/6/2004 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION PROPANE TANK AND FIREPLACE INSERT INSTALLATION TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: 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 Propane Tanks/Stoves $48.00 PRB 08/09/04 66717 Total: $48.00 ��¢Sorir cow JEFFERWJ COUNTY , ( i! _..' �'_. : ,i_�_ _ w DEPARTMENT OF COMMUNITY DEVELOPMENT 1 I i ` `4 621 Sheridan Street • Port Townsend •Washington 98368 L I >V - I 360/379-4450 • 360/379-4451 Fax I '6_, p� www.co.jefferson.wa.us/commdevelopment L___._ j RING J'-EEERSCN COUNTY Master Permit Application MLA:v-p7 nr- �,_,:.. I I`E�,Eir cF,f-,l Project Description(include separate sheets as necessary): INC P -e-AbJ c__. 16- R p,--RAee I N5 (i,S?A ZtcOJ Tax Parcel CI q A Property Number: vr�00 © l�T Size: (acres/square feet) Site Address and/or Directions to Property: / Property Owner(s)of Re rd: ,'PVC h mod- AA ,;S /6/ ✓' /�. , 1 4 ki Telephone: 4 3 7( 1. 4,, 6. Fax: email: — Mailing Address: Applicant/Agent(if different from owner): Telephone: --- _ Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) l Building ❑Variance(Minor, Major or Reasonable Economic Use) 0 Demolition Permit ❑ Conditional Use[C(a), C(d),or C]** ❑Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** ❑ Manufactured Home 0 Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan*' ❑Change of Use ❑ Long Plat** ❑Address l i Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑rropane ❑ Plat Vacation/Alteration** wed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment 0 Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent 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 its employees,representatives or agents for the sole purpose of application review and any required later inspecti s.Acces nd right of entry to this property shall be requested and shall occur only during regular business hour 4 Signature: y Signature: ^ Date: 7' '/ The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferabl responsib''ty for a er' g to a complying with the ESA. The Applicant has read this disclgre and s' ns and dates it below. Signature: Date: 9P dry I. G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • OWNER BUILDER STATEMENT • The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: 5r1,, 10/ ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE , WAINS NUMBER: AL, - 9 'r NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New ❑ Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: I I Private well i l Two Party Type of Heat: Proposed: I I Public Total: Name of System:_ If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: / i 1 Underground Tank . Above ground Tank Size of Propane Tank: / t^ l� c� I • I I Heat Stove I I Co6k Stove I i Woodstove It/ireplace Insert I I Hot W.ter Tank 0 Pellet Stove I 1 Other Is this appliance being installed in a Manufactured/Mobile Home? Yes 111, When applying for a permit to install a propane tank you must also submi • site plan showing all of the buildings,all property lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage For Office Use Only Current Proposed Amount Main Floor Consistency Review: .24.00 2Nu Floor Base fee: Ltic. 00 3rd Floor Additional Section: Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated 911/Rd Approach fee: Garage/Carport TOTAL: $ 12,(XO Decks Receipt Number: G 67 Other Cash/Check Number: �(` ESTIMATED COST(REQUIRED) Date: 67 erto V .Fair market value of all labor and materials foundation to finish Initials: p G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • ("--•( 0 '77 12-0 ct . -N • • • f ' LID - 7- , i 1-71' I • -