HomeMy WebLinkAboutBLD2004-00551 IICUILDING PERMIT APPLICA N BLD04-00551
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00551 Received Date: 8/30/2004
SITE ADDRESS: 712 JUPITER LOOP
BRINNON, 98320
OWNER: BARBARA M LEWIS PHONE:
PO BOX 12714
OLYMPIA WA 985082714
SUBDIVISION: Block: Lot: T 14
PARCEL NUMBER: 502094001 Section: 9 Township: 25 N Range: 02 W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CH1MACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTPI983O6 Expires 09/26/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI NO MLA REQUIRED U/G PROPANE TANK 1000 GALLONS - HEAT
STOVE -
COOK STOVE- HOT WATER TANK
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
ADD'L: HEAT TYPE:
CODE EDITION: 2003
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 08/30/04 67498
Total: $48.00
• OWNER BUILDER STATEMENT _
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they a id nqt licensed contractors and that
they will be assuming the responsibility of the,General Contractor for the proposed project.
Signature: })U/�,U& i f Jel c�J Date: S.,,)i v `/ I J 7
aur' 3
GENERAL CONTRACTOR OR MANUFACTURED H E INSTALLER: PHONE: FAX:
M.' )l.KAA.r CO L_,Q ( ) �+ ( )
MAILING ADDRESS: EMAIL: ; ULF I. . _.
_
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
,tiQ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
O Repair 0 Masonry SEP Permit# _
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well [_1 Two Party
Type of Heat: Proposed: ❑ 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:
fl. Underground Tank I 1 Above ground Tank Size of Propane Tank: 'CDC)
f4 Heat Stove NI Cook Stove I 1 Woodstove I Fireplace Insert I.>r Hot Water Tank I 1 Pellet Stove ❑ Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes /�i
When applying for a permit to install a propane tank you must also submit a 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: " )._1
1
2NU Floor Base fee:
3fd 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: $
Decks
Receipt Number:
Other Cash/Check Number:
ESTIMATED COST(REQUIRED) Date:
•Fair market value of all labor and materials foundation to finish
Initials:
C::\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
�'� lli c9 JEFFERSOF UNTY ��nn° �S (, Cr�,V� W ..�,^L
U �
ti 41,0 DEPARTMENT OF COMMUNITY DEVELOPMENT I I i
621 Sheridan Street • Port Townsend •Washington 98368 I r j
360/379-4450 • 360/379-4451 Fax U U AUG 3 0 2004 Ui
••q �0� www.co.jefferson.wa.us/commdevelopment I i
Master Permit Application J F`' �ui CuuENY
rEP C 16 N+am _ htrN
Project Description(include separate sheets as necessary):
Tax Parcel Property
Number: L',�v 7 yoc,i
Size: . 9 t A (acres/square feet)
Site Address and/or Directions to Poperty: 1 j 3 44 le.( i p y 0 D !. ,AM)i;A.)
• Owner(s)of Record: `/c,'b e r a \&D C _is,„3 i s � f
Telephone:lir; .71 19, --0 3 ?I Fax: email: O ft rote-1 ehid..5I K)txv c kt1
t! v\^''; .(3-<
Mailing Address: J9 O h i .36, 6yr/i/111:10 A)A- V2D
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
IBuilding 0 Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a), C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
❑Manufactured Home 0 Boundary Line Adjustment
▪ Modular 0 Short Rat**
❑ Commercial* ❑ Binding Site Plan**
❑ Change of Use El Long Plat**
❑Address I i Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
VPropane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
0 Stormwater Management 0 Shoreline Management Substantial Development**
0 Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use ill Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 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. 1
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 arty required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours. f [
Signature: ... il✓t- L`�'l t, F t ' C\ ,., :i-) Date: —r� H /
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-transferable responsibility for adharing to and complying with the ESA. The Applicant has read this discjai er and signs and dates it below.
Signature: ,bI V$jI l— liY,,C ,4L ,t,t w ',---5 Date: '
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
0 0 .- ..
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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#: BLD04-00551 Received Date 8/30/2004
SITE ADDRESS: 712 JUPITER LOOP Issue Date 8/30/2004
BRINNON, 98320
APPLICANT: BARBARA LEWI PHONE:
POBO 714 /)0-16 jc30.3
OLY IA WA 985082714 B`,A n or t, A
T 14
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 502094001 Section: 9 Township: 25N Range: 02W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTPI98306 Expires 09/26/2004
OWNER, BARBARA M LEWIS PHONE:
if different: PO BOX 12714
OLYMPIA WA 985082714
PROJECT DESCRIPTION: NO MLA REQUIRED U/G PROPANE TANK 1000 GALLONS - HEAT
STOVE -
COOK STOVE- HOT WATER 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 08/30/2005.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance: (N1A,6dr, U/G- C...
HI FinalApproval. / Li-D,5`/
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 10/29/19c
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