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Home My WebLink AboutBLD2004-00686 • • 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 #: BLD04-00686 Received Date 10/29/2004 SITE ADDRESS: 110A FAIRWAY LN Issue Date 10/29/2004 PORT LUDLOW, 98365 APPLICANT: C MICHAEL DERRIG PHONE: SALLY A SMITH 100A FAIRWAY LN PORT LUDLOW WA 98365 SUBDIVISION: FAIRWAY VILLAGE Block: Lot: PARCEL NUMBER: 951500401 Section: 21 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 9/7/2006 OWNER, C MICHAEL DERRIG PHONE: if different: SALLY A SMITH 100A FAIRWAY LN PORT LUDLOW WA 98365 PROJECT DESCRIPTION: 120 GAL ABOVE GROUND PROPANE TANK AND FIREPLACE INSERT 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 10/29/2005. REQUIRED INSPECTIONS: Tank/Line/Appliance:--1;,JK `i.ir Og //05/ fR,v4A- I P t- D/ / o'/F FinalApproval: 2K -Por V2_470fl f1 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 I UILDING PERMIT APPLICA N B RDowoa6e6 Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00686 Received Date: 10/29/2004 SITE ADDRESS: 110A FAIRWAY LN PORT LUDLOW, 98365 OWNER: C MICHAEL DERRIG PHONE: SALLY A SMITH 100A FAIRWAY LN PORT LUDLOW WA 98365 SUBDIVISION: FAIRWAY VILLAGE Block: Lot: PARCEL NUMBER: 951500401 Section: 21 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 9/7/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION 120 GAL ABOVE GROUND PROPANE TANK AND FIREPLACE INSERT 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 PRB 10/29/04 68570 Total: $48.00 �ggoly cod JEFFERSOrUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax ' �q p� www.co.jefferson.wa.us/commdevelopment 6 Z 130 S�NG�S Master Permit Application MLA: Project Description(include separate sheets as necessary): _ fn ( Tax Parcel �� 0 � Property Number: Size: LCD ‘._ (acres/square feet) Site Address and/or Directions to Property: \�� j{J�j - *; _ Property Owner(s)of Record: ` ] JZU @C1C � J- Telephone:I.` Q •)-� �� Fax: •��_ email: Mailing Address: l��-�.', T-�‘ _-- C�`1�9 �• • 8 Applicant/Agent(if different owner): � .. t-r\ �C � Telephone: �__ Fax: em . Mailing Address: What kind of Permit?(Check each box that applies) uilding ❑Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]** Single Family ❑ Discretionary"D"or Unnamed Use Classification 11 Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** Li Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** C1 Commercial* ❑ Binding Site Plan** LI Change of Use ❑ Long Plat** ❑Address CI Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments-* Propane ❑ Plat Vacation/Alteration** Allo ed"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 ❑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 attomey'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 anyd later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. p� v Signatur•: : Date:y �J• 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 e in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfer le responsibility for adhering to and mplying_with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: Date: ( Cm • 7 �. C G:\PennitCenter\FORMS\DRD FO \Master Permit Application 7-8-04.doc leOWNER BUILDER STATEMENT i 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 MANUFACTUREDAN"�✓ ' HOME INSTALLER: PHONE: FAX: C-- o ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: 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: ❑ Private well ❑ 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: ❑ Underground Tank Above ground Tank Size of Propane Tank: (Zto LiHeat Stove ❑ Cook Stove Cl Woodstove Fireplace Insert ❑ Hot r Tank L7 Pellet Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home? Yes No j 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 d Consistency Review: 24.CID 2'"'Floor GOO Base fee: O 3"'Floor (� Additional Section: D Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated 911/Rd Approach fee: Garage/C- poet €C� TOTAL: $ ?Z �9O Decks / 6$��O L Receipt Number: b Other 7 Cash/Check Number: O� ESTIMATED COST(RE UIRED) Date: O/2Q CA— •Fair market value of all labor and materials foundation to finish Initials: `Vie; G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 7 c4\-6PV" OCT 2 9 2004