HomeMy WebLinkAboutBLD2004-00669 •UILDING PERMIT APPLICA•N BL Review T Ty y669
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00669 Received Date: 10/22/2004
SITE ADDRESS: 71 SIMCOE RD
PORT TOWNSEND, 98368
OWNER: MICHAEL M HENERY PHONE: (360) 379-0646
JANE A HENERY
71 SIMCOE RD
PORT TOWNSEND WA 98368-9657
SUBDIVISION: Block: Lot: T28+
PARCEL NUMBER: 001324011 Section: 32 Township: 30 N Range: 01 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 DESCRIPTIOI 120 GAL A/G PROPANE TANK, GAS PIPING AND 2 GAS INSERTS
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 2003 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 KAS 10/22/04 67930
Total: $48.00
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ADDRESS PHONE #:
DIRECTIONS FAX #:
Email
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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 #: BLD04-00669 Received Date 10/22/2004
SITE ADDRESS: 71 SIMCOE RD Issue Date 10/22/2004
PORT TOWNSEND, 98368
APPLICANT: MICHAEL M HENERY PHONE: (360) 379-0646
JANE A HENERY
71 SIMCOE RD
PORT TOWNSEND WA 98368-9657 T28+
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001324011 Section: 32 Township: 30N Range: 01W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2004
OWNER, MICHAEL M HENERY PHONE: (360) 379-0646
if different: JANE A HENERY
71 SIMCOE RD
PORT TOWNSEND WA 98368-9657
PROJECT DESCRIPTION: 120 GAL A/G PROPANE TANK, GAS PIPING AND 2 GAS INSERTS
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 10/22/2005.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: 7/11Jjt,A17-- �' c' FX // -oZ-o
FinalApproval: i,,,,- I - )- 19--4
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
`JEFFERSON COUNTY COMMUNITY VELOPMENT.621 SHERIDAN ST.PORT TOWNSEND A 98368 PH: (360)379-4450
I ALLATIOK PERMIT APPL
ICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO THIS INSTALLATION
Underground PROPANE TANK* V Above Ground PROPANE TANK* SIZE OF PROPANE TANK /
HEAT STOVE HOT WATER TANK WOODSTOVE FIREPLACE INSERT PELLET STOVE
COOKING STOVE x OTHER(Please Specify) �Lt • 2 ���J vy��i 6
Is this appliance(woodstove, htgstove, hot water tank furnace, etc.) jf to be installed in a Manufactured/Mobile
Home?
• YES x NO
SITE ADDRESS(911#/Road Name):
7 S- c�cr
ZIP
9 DIGIT PARCEL ID NUMBER CO U ( 3 v 0 l/
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range — WM
APPLICANT PHONE
•
MAILING ADDRESS ;}
ZIP
PROPERTY OWNER o- cL.�4- PHONE 1v11- --(
MAILING ADDRESS c-- L c
ZIP
CONTRACTOR S L- Y1 S N Ill (-2_^ I r C O c 4A.D..._ PHONE 3 s' J 7 7
MAILING ADDRESS n/ O e j13 1t`1 uc{� (I •
Pol^T hIadLC3ck I ) ZIP 3�]
STATE LICENSE# L1�1 S HC Dr-7 7 Q IJ EXP.DATE I I/Q Lt
FEDERAL I.D.# 9 1 - 1 Q 7 85'7
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 property or structure shall be requested and shall occur during regular business hours.
APPLICANTS SIGNATURE DATE /
FOR OFFICE USE ONLY /`�
BASE FEE $48.00 RECEIPT# (7'(r 50
CONSISTENCY REVIEW $24.00 CASH/CK# o CD g
TOTAL I ).l i O DATE I O /o /O ti-
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