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Home My WebLink AboutBLD2004-00797 0 • 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 #: BLD04-00797 Received Date 12/16/2004 SITE ADDRESS: 170 HERBERT ST Issue Date 12/16/2004 QUILCENE, 98376 APPLICANT: QUILCENE MASONIC HALL ASSOC PHONE: PO BOX 63 QUILCENE WA 98376-0063 3-5 SUBDIVISION: CAMPBELL'S H.W. ADDITION Block: 11 Lot: PARCEL NUMBER: 937201106 Section: 24 Township: 27N Range: 02W CONTRACTOR: DANA'S HEATING INC PHONE: (360) 876-7670 PO BOX 607 BURLEY WA 98322 (3 l 87B Contractor's License DANASHI000DZ Expires 08/23/2005 3177 OWNER, QUILCENE MASONIC HALL ASSOC PHONE: if different: PO BOX 63 QUILCENE WA 98376-0063 PROJECT DESCRIPTION: 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 12/16/2005. REQUIRED INSPECTIONS: Tank/Line/Appliance: _ FinalApproval: (,Z" 21—O ( 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 10/29/1a INUILDING PERMIT APPLICAN BLD04-00797 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00797 Received Date: 12/16/2004 SITE ADDRESS: 170 HERBERT ST QUILCENE, 98376 OWNER: QUILCENE MASONIC HALL ASSOC PHONE: PO BOX 63 QUILCENE WA 98376-0063 SUBDIVISION: CAMPBELL'S H.W. ADDITION Block: 11 Lot: 3-5 PARCEL NUMBER: 937201106 Section: 24 Township: 27 N Range: 02 W CONTRACTOR: DANA'S HEATING INC PHONE: (360) 876-7670 PO BOX 607 BURLEY WA 98322 gg 33 Contractor's License DANASHI000DZ Expires (308ggpp)23/200577 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION 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 12/16/04 68919 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 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: `� N I YiC. >E3 77—7/'7O (.o 76-3117 MAILING ADDRESS: p C `� S1A EMAIL: CONTRACTOR'S LICENSE 70Fl a 4 a ��'Z I11 WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PI-LONE ( ) FAX: ( MAILING ADDRESS: EMAIL - - Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: J New LI Wood Existing: a Sewer J Addition Li Steel Proposed: Bank u Community System Xi Alteration/Remodel LL Concrete Total: Height LJ Individual System _l Repair a Masonry SEP Permit# J Demolition a Other. Bedrooms: Water Supply: Existing: Setback: Li Private well LI Two Party Typeof Heat Proposed: Li 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: 1 Underground Tank 1 Above ground Tank Size of Propane Tank c / 5 r1CS Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 Other 1 ' 1 ' Fla Is this appliance being installed in a Manufactured/Mobile Home? Yes / No Z- �{il ifC`1f a, 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: 2Nu Floor Base fee: 1 jc .-Pro n e_ I4S.00 3fa 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: $ 4S 00 Decks Q Receipt Number: . 0' Other Cash/Check Number: 101 U l ESTIMATED COST(REQUIRED) ' 9 \/f �: !, :` Z AI,/ / •Fair market value of all labor and materials foundation to finish L Initials! ,.: : y 1 6 20114 �' • L C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc I. .� : i, r"; n�d rry 'tf (,,'..�.::its i'1 LCLV r, +�a11 ¢70N ! i� l� l� k`r/ f y 4� cpG JEFFERs�COUNTY I �- 4 DEPARTMENT OF COMMUNITY DEVELOPMENT A �' ., '� 621 Sheridan Street• Port Townsend •Washington 98368 ir`. ll! • 1b Li U , 360/379-4450 • 360/379-4451 Fax I t t �9S �p� www.co.jefferson.wa.us/commdevelopment PIING j -�,- w {. Master Permit Application Pr9jpct Description(include separate sheets 4,k necessary): `, p kn(t Z c \ I u maces l c)i-\-h 2 prupnE. ' U. t r Tax Parcel n /�/ Property Number. "1 ; l l V/-ICJ 1 Size: 1 (acres/square feet) Site Address and/or Directions to Property: 1-1 v H((b(�1 1 s4. Property Owner(s)of Record: 01( .:inky) 1 c c c C. Telephone: Fax: email: I I( t-ICNk._ i C�e.r�s . MailingAddress: ( t f -��,. Applicant/Agent(if different from owner): O--Y1(L I ea k-1 Y1 • fC - Telephone.3&'O— -lb`- Co"7Cj Fax 3(OQ-Mb"3 I email:YYLL)YY�i j I�?l' . Mailing Address:�,0:BO (aC) 7 E net i �� - E 2 Z. (.' 1'ie,C'OYVI 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 Cj** 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" ❑ Address 'Road Approach CI Planned Rural Residential Development(PRRD)/Amendments** XPropane U Plat Vacation/Alteration** U Allowed"Yes"Use Consistency Analysis U Shorekne Master Program Exemption/Permit Revisions'* U Stormwater Management U Shoreine Management Substantial Development** U Site Plan Approval Advance Determination(SPAAD)* U Shoreine Management Variance U Temporary Use U Comprehensive Plan/UDC/Land Use District Map Amendment U Wreless Telecommunication* U Jefferson County Shoreline Master Program Amendment U 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 pi required later ins . ns.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Jf; Signature MC1 l Date: /Z—/�i o Li L i e� The action or actions Applicant 'II 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 lawiknown 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)ev if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-trio 2-ferable res nsibi for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature' ✓I�lf.�1 )ztttLDate: 1 —16 -L)L/ y C:\Documents and Settings\mocha\Desktop\Master Permit Application 7-8-04.doc