HomeMy WebLinkAboutBLD2004-00677 IUILDING PERMIT APPLICAS)N BL Revviewiew TyTy677
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD04-00677 Received Date: 10/27/2004
SITE ADDRESS: 9122 RHODY DR
CHIMACUM, 98325
OWNER: GREG MC PHERSON PHONE:
PO BOX 266
CHIMACUM WA 98325
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901142021 Section: 14 Township: 29 N Range: 01 W
CONTRACTOR: POWELL MECHANICAL PHONE: (360)340-4428
PO BOX 874
PORT ORCHARD WA 98366
Contractor's License SUBURPL044DA Expires 3/12/2005
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP 250 GAL ABOVE GROUND PROPANE TANK AND HEAT STOVE
INSTALLATION
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:
GARAGE: SHORELINE:
CONST TYPE: 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 Flood plain
Routing Date: (O1/.1 (ocr Pj2$ S&W Landslide
I Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $48.00 PRB 10/25/04 68562
Total: $48.00
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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 #: BLD04-00677 Received Date 10/27/2004
SITE ADDRESS: 9122 RHODY DR Issue Date 10/27/2004
CHIMACUM, 98325
APPLICANT: GREG MC PHERSON PHONE:
PO BOX 266
CHIMACUM WA 98325
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901142021 Section: 14 Township: 29N Range: 01W
CONTRACTOR: POWELL MECHANICAL PHONE: (360)340-4428
PO BOX 874
PORT ORCHARD WA 98366
Contractor's License SUBURPL044DA Expires 3/12/2005
OWNER, PATRICK J SMITH PHONE:
if different: PO BOX 266
CHIMACUM WA 983250266
PROJECT DESCRIPTION: 250 GAL ABOVE GROUND PROPANE TANK AND HEAT STOVE
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 10/27/2005.
REQUIRED INSPECTIONS:
TanWLine/Appliance: AL. ��`` /0"/
FinalApproval: Ov -c /0- CY
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
• ~ • •
("--.;.44. ozv �06. JEFFERSON COUNTY
a''';, A DEPARTMENT OF COMMUNITY DEVELOPMENT
'' ```L, 'r 621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/379-4451 Fax OCT 2 5 2004
0 www.co.jefferson.wa.us/commdevelopment
11/49
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Master Permit Application MLA:
Project Description(include separate sheets as necessary):
PP�PAQa 7?Ao3 it * H k-7QL- losz1 - LA1co l•S
Tax Parcel Property
Number: ' O/ �t-{ 2- O 2- ( Size: l
I / i /--. ,e v 5. (acres/square feet)
Site Address and/or Directions to Property: Ci( 7. 2- O O7 n2- /cf-tf rt-tv4,1 ! w,q 'Y�
Property Owners)of Record: PA-I- cm21 TJ-I
Telephone: 3 to D 3 2- 4
c 3 ( Fax: email:
Mailing Address: 613.xC 2._Cc. L.-44(nri/9- i cl,11 w/4—c( i•32,r
Applicant/Agent(if different from owner): C2h6 y t'7J/4�rzszzAi / (se,c6 74,4-39-73
Telephone: 3 GO --'73 0U0 Fax: email:
Mailing Address: r 2.-o,( cis-C , /yi 1//G(/n" C.--A- -7 Y3 y(
What kind of Permit?(Check each box that applies)
U Building U Variance(Minor,Major or Reasonable Economic Use)
U Demolition Permit U Conditional Use[C(a),C(d),or C]**
U Single Family U Discretionary"D"or Unnamed Use Classification
U Garage Attached/Detached U Special Use(Essential Public Facilities)**
U Manufactured Home U Boundary Line Adjustment
U Modular U Short Plat**
U Commercial* U Binding Site Plan**
U Change of Use U Long Plat**
U Address i Road Approach U Planned Rural Residential Development(PRRD)/Amendments**
)Propane U Plat Vacation/Alteration**
U Allowed"Yes"Use Consistency Analysis U Shoreline Master Program Exemption/Permit Revisions**
U Stormwater Management U Shoreline Management Substantial Development**
U Site Plan Approval Advance Determination(SPAAD)* U Shoreline Management Variance
U Temporary Use U Comprehensive Plan/UDC/Land Use District Map Amendment
U Wireless Telecommunication* U Jefferson County Shoreline Master Program Amendment
i 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:
G i DESIGNATION OF AGENT
I hereby designate •�!/V� !�' - 1 / to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURJotLk/I!IQ\ Q_a/� �/�� Date: / �' � 3- c U (-/
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 inspections.Access and right oft ent ry to this property shall be requested and shall occur only during regular business
hours.
Signature: Date: / o" , C--- Q d 6 �-/
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 1
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-transfe respon 'b� it .jr,f adhering to and complying with the ESA. The Applicant has read this disclaim r and igns and dates it below.
Signature: ,( �� rl Date: /C�Z l�e v
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc
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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 as in esponsibility of the General Co tractor for the proposed project.
Signature: Gj �r ��� " t� ate: /I)/2 , a
Sc9( 0 2.43 VRor)P,6s+J L.-- - So 9 „9CT 2 5 2004
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: F
Powilk z- (3(c0 ) 3YO-YY 2-'. (365)&7V Oics
MAILING ADDRESS: 60? 7 Po 1 v ecevreo EMAIL:
CONTRACTOR'S LICENSE r/fv 76 6 WAINS
Q
NUMBER: f GC.</C sill 7 I LTJ NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
I New ❑ Wood Existing: 1 Sewer
Addition ❑ Steel Proposed: Bank 1 Community System
Alteration/Remodel ❑ Concrete Total: Height: I Individual System
❑ Repair ❑ Masonry SEP Permit#
i i Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: I Private well I 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:
I Underground Tank (Above ground Tank Size of Propane Tank: 2 ) Gf4-4- •
xtieat Stove I Cook Stove I Woodstove I Fireplace Insert I Hot Water Tank I Pellet Stove I Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / S
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: <� �rC)
ju`�
2"u Floor Base fee: (9,14
T OD
3ra Floor Additional Section: "I ,-------
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport
TOTAL: $ `7 Z
Decks
Receipt Number: • •t<ct
Other Cash/Check Number: C L 39
ESTIMATED COST(REQUIRED) Date: t _/
.Fair market value of all labor and materials foundation to finish [G(��
4. ( S) J Initials: V la.-z
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc
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