HomeMy WebLinkAboutBLD2005-00041 1RJILDING PERMIT APPLICA1 Review TyN BL Ty041
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Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00041 Received Date: 1/20/2005
SITE ADDRESS: 2000 OLD GARDINER RD
SEQUIM, 98382
OWNER: JEFFERSON CO FIRE DISTRICT#5 PHONE: (360) 797-7711
2000 OLD GARDINER RD
SEQUIM WA 98382-8750
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 002343021 Section: 34 Township: 30 N Range: 02 W
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 DESCRIPTION TANK SWAPOUT(500 GAL A/G), TWO HEATERS AND GAS PIPING
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: $49.00
• I
PROPANE/PELLET/WOOD STOVE & TANK INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD05-00041 Received Date 1/20/2005
SITE ADDRESS: 2000 OLD GARDINER RD Issue Date 1/21/2005
SEQUIM, 98382
APPLICANT: SUNSHINE PROPANE PHONE: (360) 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 002343021 Section: 34 Township: 30N Range: 02W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2006
OWNER, JEFFERSON CO FIRE DISTRICT#5 PHONE: (360) 797-7711
if different: 2000 OLD GARDINER RD
SEQUIM WA 98382-8750
PROJECT DESCRIPTION: TANK SWAPOUT(500 GAL A/G), TWO HEATERS AND GAS PIPING
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 01/21/2006.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:S/C,Ac
1 /k
FinalApproval: j/1 NJCiC /—:1�,�� }--in1,.�YL I,,/ c�AO 3 � L._.
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
I:\F_BLD_Permit_Propane.rpt 10/29/19c
Jan 20 05 03: 42p I 1 -360-385-5875 p. 2
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SITE VISIT REPORT
(PLOT PLAN)
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ADDRESS ZovG +� . • CONTACT: P))N CoO -t
Ic r r N �r` RP PHONE #: 3t.4.,O_-1 7 7`f-! ( .
DIRECTIONS FAX #: 36O-`ir 9 3-72$p, ,
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49.4ON C'p6. JEFFERSON C*INTY • .�: 'I
' 4-' DEPARTMENT OF COMMUNITY DEVELOPMENT
lfir44.4
621 Sheridan Street • Port Townsend •Washington 98368 -
360/379-4450 • 360/379-4451 Fax 2-0
4.<q O www.co.jefferson.wa.us/commdevelopment
S NCI.S
CO)Master Permit Application MLA: tl '� RSON G��N "
Project Description(include separate sheets as necessary):
/
Tax Parcel OD 2 3`{3 O L Property
Number: 1 Size: (acres/square feet)
Site Address and/or Directions to Property: �-ED o O O L GAa^0(ha.-/ 2 o . S0-0 6( /Art_
Property Owner(s)of Record: -le e-{-S U .-.. C 7 _ -,1 6 r e O,51-, li ,5
Telephone: 75 7 - 7 7// Fax: 7 S-7- 7.)-S J email:
Mailing Address: a-ocsc, 0(--,0 C- -r - 1<-3 FL
Applicant/Agent(If different from owner): �t.-_.-4_/,- a-)rQY,
Telephone: 3 B 5 S 75 7 Fax: 3 cYS 5 c 7s email:
Mailing Address: /'0 8S-3 PG 1)r. j)i. .-.c-C-0,-k , c,;-- 5-cf3_3 f
What kind of Permit?(Check each box that applies)
0 Building ❑ Variance(Minor, Major or Reasonable Economic Use)
0 Demolition Permit 0 Conditional Use[C(a), C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)"
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat"
❑ Commercial* 0 Binding Site Plan"
❑ Change of Use ❑ Long Plat"
❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
$Propane ❑ Plat Vacation/Alteration*"
u Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions"
0 Stormwater Management ❑ Shoreline Management Substantial Development"
❑ Site Plan Approval Advance Determination(SPAAD)* 0 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).
--)DWNER SIGNATURE, /� � ..— Date: J-/Cj--G'.S
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 ifs 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 Inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
ignature:�AV,.r...,•,L �.— Date: s
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-transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
.---- I nature:�}iH Date: ( '/ ? e-
G:\Permitcenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
�3S°
OWNER BUILDER STATEMENT •
The signer of this statement does hereby certifyIIPthey 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:
( ) ( )
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
O Addition ❑ Steel Proposed: Bank U Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
0 Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: El Private well 0 Two Party
Type of Heat: Proposed: ❑ Public
Total: Name of System:
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:
❑ Underground Tank V Above ground Tank Size of Propane Tank: 50' 2----r •
It ((2s Ll_ti'l i Nearer. Cook Stove ❑ Woodstove Li Fireplace Insert [1 Hot Water Tank 0 Pellet Stove DO Other c -0 p
Is this appliance being installed in a Manufactured/Mobile Home? Yes / No a war
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:
2""Floor Base fee:
Floor I- Base
I `7 rl n _ 141' �!U
Additional Section:
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement n WI
(�`" Pot Water Review fee:
Other Unheated La 911/Rd Approach fee:
Garage/Carport t
I , ! r TOTAL: $
Decks
Receipt Number: / ! J •�
Other "'''�� ! Cash/Check Number: �AP
2lLo I
ESTIMATED COST(REQUIRED) Date:
.Fair market value of all labor and materials foundation to finish 1. ��
Initials:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc