HomeMy WebLinkAboutBLD2005-00012 RILDING PERMIT APPLICAT BLD05-00012
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00012 Received Date: 1/6/2005
SITE ADDRESS: 543 PARKRIDGE DR
PORT TOWNSEND, 98368
OWNER: GENEVIEVE P GORSKI TRSTEE PHONE: (541) 740-9013
STANLEY R GORSKI TRSTEE
260 KALA POINT DR
PORT TOWNSEND WA 98368
SUBDIVISION: WOODLAND HILLS #2 PHASE 2 Block: Lot: 60 +
PARCEL NUMBER: 999900160 Section: 27 Township: 30 N Range: 01 W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 09/26/2006
REPRESENTATIVE: KELLEY SHIELDS INC PHONE:
260 KALA POINT DR
PROJECT DESCRIPTIOr A/G 120 GAL PROPANE TANK, GAS PIPING, HEAT STOVE AND
COOK STOVE
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION
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 01/05/05 69027
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 #: BLD05-00012 Received Date 1/6/2005
SITE ADDRESS: 543 PARKRIDGE DR Issue Date 1/6/2005
PORT TOWNSEND, 98368
APPLICANT: GENEVIEVE P GORSKI TRSTEE PHONE: (541) 740-9013
STANLEY R GORSKI TRSTEE
260 KALA POINT DR
PORT TOWNSEND WA 98368 60 +
SUBDIVISION: WOODLAND HILLS#2 PHASE 2 Block: Lot:
PARCEL NUMBER: 999900160 Section: 27 Township: 30N Range: 01W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 09/26/2006
OWNER, GENEVIEVE P GORSKI TRSTEE PHONE: (541) 740-9013
if different: STANLEY R GORSKI TRSTEE
260 KALA POINT DR
PORT TOWNSEND WA 98368
PROJECT DESCRIPTION: A/G 120 GAL PROPANE TANK, GAS PIPING, HEAT STOVE AND
COOK STOVE
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 01/06/2006.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:i l6.- L//J . 30 /°SI t. I- 7'
FinalApproval: — 344) >,
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
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JEFFERSOIl�OUNTY •
1,0041‘6,
1 DEPARTMENT OF COMMUNITY'DEYELOI5MENT-71 n�/n�--(r-----
621 Sheridan.Street •.Port Townsend...t Washington b8358 tg
360/379-4450 • 360/379-4451 Fax
�iS ��0� www.co.jefferson.wa.us/commdevelopme I I
JAN - 5 hi 'I
Master Permit Application
MLA:
Project Description(include separate sheets as ne ssary):
o Awe. "f'A-IS+L FoL. P' A) OD wtt-
Tax Parcel QQ (� Property
Number: l l 100 (Coo Size: -D P C (acres/square feet)
Site Address and/or Directions to Property: 543 PAAg.. rzl DG to 4 L. __Rift •
Property Owner(s)of Record:.. rAbi J a Das44 I
Telephone: • ___:.0 — la : flax: email:
Mailing Address: 160 ' , Da. • ).•r• . T�j;(Np
Applicant/Agent(if different fr m owner):—Ekrasj l u fjr:o t rA , . C u �. ,)
Telephone: 3t 5• '1 t S V Fax: emaill— ��i3eLl
Mailing Address: Z.( gelL S- 6 * b, . • V .7- ' (b 3(p
What kind of Permit?(Check each box that applies) ,
❑ Building 0 Variance(Minor, Major or Reasonable Economic Use)
0 Demolition Permit ❑ Conditional Use[C(a),C(d),or C]**
0 Single Family 0 Discretionary"D"or Unnamed Use Classification
0 Garage Attached/Detached 0 Special Use(Essential Public Facilities)**
❑Manufactured Home 0 Boundary Line Adjustment
0 Modular 0 Short Plat**
0 Commercial* 0 Binding Site Plan**
0 Change of Use 0 Long Plat**
0 Address 0 Road Approach 0 Planned Rural Residential Development(PRRDyAmendments**
*Rrppane 0 Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
0 Temporary Use 0 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 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 any required later ins ctions.Arrx.cs and right of entry to this property shall be requested and shall only during regular business
hours. •
Signature: V le- gm...ax
/ Date: ` ) ; ) V 5
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-tran a responsi "ty hering and poAplyi wi the ES e A licantt has read this disc ime)and signs and dates it below.
Signature: V 1 aw Date: 1 110 5
G:\PermitCenter\FORMS\DAD FORMS\Master Permit Application 7-8-04.doc
OWNER BUILDER STATEMENT
The sigcier 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-wilt be:assuminglhe responsibility of the General Contractor for the proposed project.
Signature:
Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER:
PHONE: FAX:
MAILING ADDRESS: (3`"0) 3 (pGi�3( )
N1 V4, IIN 1 EMAIL:
CONTRACTOR'S LICENSE C,et t Hr►141.0111444 t W M
NLS WAINS
UMBER:
ARCHfTECT/ENGINEER: �as NUMBER
MAILING ADDRESS: PHONE ( ) FAX:( )
EMAIL
ProJect::Type: ..:.,.:„ .:.,
❑ New frame Type: - Bathrooms: -: --:Shoreline:
❑ Wood Existing: Type of Sewage Disposal:
❑ Addition ❑ Steel Proposed: CI Sewer
❑ Alteration/Remodel ❑ Concrete Total: Heg ❑ Commualty stemm
❑ Repair CI Masonry
Height: ❑ Individu System
0 Demolition ❑ Other. Bedrooms: SEP Permit#
Type of Heat: Existing: Setback: Water Supply
Proposed: ❑ Private well ❑ Two Party
Total: — ❑ Public
Name of System:
If this is a Commercial Pro ect ou must answer the followin :
Number of Parking Spproposed nt:
aces: Curre
Number of occupants(includes owners,tenants,employees,etc) CurrentNumber of ADA Parking Spaces:
IBC Occupancy: IBC TypeProposed
of construction: Will you have Food Service? Yes / No
If this Is a Pro ane Tank and/or A fiance Installation rmit mark all items below that a I .
tO *Above Tank Above ground Tank
LI Heat Stove Size of Propane Tank: �'� G k�.,
.Cook Stove ❑ Woodstove c Fireplace Insert 0 Hot Water Tank ❑ Pellet Stove 0 Other
Is this a liance bean Installed In a Manufactured/Mobile Home? Yes / No
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 systemcom p nts,
includin. the reserve area. components,
S.uare Foota.e E t; i i fi
Main Floor IMEMEMII Pro..seda ,. L t, ,, a a �, } ,
1 � 'i Y ^Y4;'-7-1 . r G� fi y
r �+ . v. ti�ti w�. Fr�rti <d � r� - v
writ » '
2' Floor 3 � w.�i , '�} '�.,• �Rv y'kt'�� s.ar 3�r� _k '�' t� �6;
. A , a mc- . -" Via' xl. :77 ..
3' Floor :, �` —
si �° 0."a y. .+4�r}a ,,v ^�<t.Yt- _ n as
Mezzanine: FT h h .` �
Heated Basement _� 4` ° I +,4, ,�'„°.'' `a'it`''a° is S i' : _
_ -i,Pii , .. ..s k';+31„in„x .Y,si�•,.:3 F # ty� �y,�..s 3TG_
c i's..ryl,.4� �p'm' y.!t'ey � _ ii ,.t , u _ _ w ..
Unheated Basement �y � y wage 3 €= s c4z a a ? Ta�akr�Stwxc i�t < � =
Other Unheated ;u ';h '• ra ';.�4 ` ; ; 5 , ' CAn
E• t C �l r1 q'�n
Decks 11e ,ti'1 r<x `' & ?f-'4!_ .1�• ` = g"E'"�1 ''4 A �q r. ;
svR" �x� a t
�4 s3 jets, , i �t`, _y;f a't3"-� -�f .T,3,,'•�t .
Other ` < t s
air } aa. xw i y ,
ESTIMATED COST(REQUIRED) 4
•Fair market value of all labor and materials foundation to finish ?Iu.i��� '`
G:\PennitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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