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Home My WebLink AboutBLD2005-00039 IUILDING PERMIT APPLICA1N B RDOe 00039 Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00039 Received Date: 1/20/2005 SITE ADDRESS: 191 DISNEY RD NORDLAND, 98358 OWNER: KEVIN M MILLER PHONE: (360) 385-5563 SUSAN E MILLER 191 DISNEY RD NORDLAND WA 98358-9535 SUBDIVISION: Block: Lot: T 46+ PARCEL NUMBER: 921094027 Section: 9 Township: 29 N Range: 01 E CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797 10853 RHODY DR PORT HADLOCK WA 98339 Contractor's License SUNSHP*077QP Expires 11/17/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOP INSTALL COOKSTOVE AND GAS PIPE 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: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: 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 $49.00 KAS 01/20/05 69124 Total: $49.00 • 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 #: BLD05-00039 Received Date 1/20/2005 SITE ADDRESS: 191 DISNEY RD Issue Date 1/20/2005 NORDLAND, 98358 APPLICANT: SUNSHINE PROPANE 10853 RHODY DR PHONE: (360) 385-5797 PORT HADLOCK WA 98339 SUBDIVISION: T 46+ Block: Lot: PARCEL NUMBER: 921094027 Section: 9 Township: 29N Range: 01 E CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797 10853 RHODY DR PORT HADLOCK WA 98339 Contractor's License SUNSHP*077QP Expires 11/17/2006 OWNER, KEVIN M MILLER PHONE: (360) 385-5563 if different: SUSAN E MILLER 191 DISNEY RD NORDLAND WA 98358-9535 PROJECT DESCRIPTION: INSTALL COOKSTOVE AND GAS PIPE 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 01/20/2006. REQUIRED INSPECTIONS: Tank/Line/Appliance: FinalApprova 7/17 t6 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 (rvsON - IJ 6 JEFFERSON NTY i �-- .-7"t`Th ` DEPARTMENT OI- COMMUNITY DEVELOPMENT 1-4 \ I)) 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax 1 .0 www.co.jefferson.wa.us/commdevelopment • • ,l A_t4 %NG Master Permit Application MLA: [rnC'fN COT ""'1 Project Description(include separate sheets as necessary): _kytS� ✓� i'Err L1:J A ''2p Tax Parcel / "' / O // a d2 Property Number: `f Size: (acres/square feet) Site Address and/or Directions to Property: 1 9,1 Q j S /f e4f R D , Property Owner(s)of Record: Ke r/I kLs S(-es,q-ram �f m I[_LC j2 Telephone: 3 8 S `� 563 Fax: email: Mailing Address: SI iE Applicant/Agent(if different from owner): .S t<V? S' - e IJ12..0-->de- -.-Q __ , Telephone: 3 g S S 77 7 Fax: email: Mailing Address:J Za SS3 0!'. ?j C,.Jc_ What kind of Permit?(Check each box that applies) ❑ Building 0 Variance(Minor, Major or Reasonable Economic Use) 0 Demolition Permit 0 Conditional Use[C(a),C(d),or C)** 0 Single Family 0 Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached 0 Special Use(Essential Public Facilities)*" 0 Manufactured Home ❑ Boundary Line Adjustment 0 Modular 0 Short Plat" ❑ Commercial' 0 Binding Site Plan" 0 Change of Use 0 Long Plat** dress 0 Road Approach 0 Planned Rural Residential Development(PRRD)Amendments" pane 0 Plat Vacation/Alteration** Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management 0 Shoreline Management Substantial Development" 0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance 0 Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment o 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 l� "� to act as my agent in matters relating to this application for permit(s). �WNER SIGNATURE t L,/ . f��1�_WV Date: By signing this application f ,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or Ws 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 attorneys 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 ccess and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any requir later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. /JiJ 74 i�� >Signature: (�/b L �/�-- Date: 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 'II 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 ar In compliance with the Jefferson County development code.The Applicant acknowledges that he,she or It holds individual and non-transfe ble nsibilir pdtyey�ng d complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. --- Signature: (e GG Date: G:\PermitCenter\FORMS DRD FORMS\Master Permit Application 7-8-04.doc OP) OYL:'LR BUILDER STATEMENT The signer of this statement does hereby certify thit ey are the Owners of the parcel referenced herein,tha 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: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTORS LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New ❑ Wood Existing: 0 Sewer O Addition 0 Steel Proposed: Bank ❑ Community System O Alteration/Remodel 0 Concrete Total: H Ight: 0 Individual SyStelii LI Repair 0 Masonry SEP Permit# O Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: L] Private well ❑ Two Party Type of Heat: Proposed: LI Public Total: Name of System: r-- If this is a Commercial Protect 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: LI Underground Tank ❑ Above ground Tank Size of Propane Tank: U Heat Stove Cook Stove ❑ Woodstove ❑ Fireplace Insert 0 Hot Water Tank [ Pellet Stove X Other j a S p V f Is this applia ce being installed in a Manufactured/Mobile Home? Yes(o) 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: —270 Floor Base fee: ' , (1- _ 3 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 i t ti TOTAL: $ 4 .0o Decks Receipt Number: ' 1 2-4 11 Other JAN 2 2005 Cash/Check Number: tU q _ ESTIMATED COST(REgUIRED)___. f Date: •Fair market value of all labor and materials foundation to finish l 16 t Initials: i G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc