HomeMy WebLinkAboutBLD2005-00329•
S •
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 #: BLD05-00329 Received Date 5/23/2005
SITE ADDRESS: 131 HIGHLAND GREENS#3 Issue Date 5/24/2005
PORT LUDLOW, 98365
APPLICANT: DIANE KOBZ PHONE: (360)437-0724
131 HIGHLAND GREENS#3
PORT LUDLOW WA 98365
UN40:
SUBDIVISION: HIGHLAND GREENS BLDG 4 Block: Lot:
PARCEL NUMBER: 959500018 Section: 21 Township: 28N Range: 01 E
CONTRACTOR: FERRELLGAS PHONE: (360)779-7567
646 SO 3RD AVE
SEQUIM WA 98382
Contractor's License FERRELP055LH Expires 08/01/2006
OWNER, DIANE KOBZ PHONE: (360)437-0724
if different: 131 HIGHLAND GREENS#3
PORT LUDLOW WA 98365
PROJECT DESCRIPTION: PROPANE TANK, COOK STOVE, INSERT, BBQ 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 05/24/2006.
REQUIRED INSPECTIONS:
TanWLine/Appliance: 04sNK /Lie/# orF -MC ` C� g
FinalApproval: OK for ci ta,! �r'z7inSC"
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£
WILDING PERMIT APPLICATIN B RDOe 00329
Type:
Jefferson County Department of Community Development
•
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00329 Received Date: 5/23/2005
SITE ADDRESS: 131 HIGHLAND GREENS#3
PORT LUDLOW, 98365
OWNER: DIANE KOBZ PHONE: (360)437-0724
131 HIGHLAND GREENS#3
PORT LUDLOW WA 98365
HIGHLAND GREENS BLDG 4
SUBDIVISION: Block: Lot: UN40:
PARCEL NUMBER: 959500018 Section: 21 Township: 28 N Range: 01 E
CONTRACTOR: FERRELLGAS PHONE: (360)779-7567
646 SO 3RD AVE
SEQUIM WA 98382
Contractor's License FERRELP055LH Expires 08/01/2006
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI PROPANE TANK, COOK STOVE, INSERT, BBQ 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:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $49.00 KAS 05/23/05 73095
• Total: $49.00
���¢goN cO rJEFFERSO.OUNTY •
DEPARTMENT OF COMMUNITY DEVELOPMENT
`-' ` ` 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
tS www.co.jefferson.wa.us/commdevelopment
Is,
Master Permit Application MLA:
Project Desc/iption(include separate sheets as necessary): 7�
�oW ( ft 4 670 U 2 /f4,SPN'r , RQ,l/'c.�a. 4'gc pi,oTax PafTh'p /MP
l 'Property v J
Number: fL5 (5000!g Size: (acres/square feet)
Site Address and/or Directions to Property: /3/ ! lama C?teems 3
Property Owner(s)of Record: -
Telephone- Fax: I of email:
Mailing Address: l3/ /f l i fe4 i ,/ 6 r°e is -Z��3 Po rsr i._U410 by rvil " r
Applicant/Agent(if differe t from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
Li Building CI Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a),C(d), or C]**
❑ Single Family t"] Discretionary"D"or Unnamed Use Classification
❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑ Manufactured Home ❑ Boundary Line Adjustment
❑ Modular Li Short Plat**
❑ Commercial* [i Binding Site Plan**
❑ Change of Use r- ---- -----ti Long Plat"----
D Address I I Road Approach ' ❑ Planned Rural Residential Development(PRRD)/Amendments**
Propane r ---fE Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions*"
❑ Stormwater Management MAY 2 Spline Management Substantial Development**
❑ Site Plan Approval Advance Determination(SPAAD)* D Shoreline Management Variance
❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* r1 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 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 pro ' e access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any re r d later inspection A ss and right of entry to this property shall be requested and shall occur only during regular business
hours. —
Signature: — Date: /47 ,2L 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 r are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf: e responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: / d Date: /)". ,2 3 ,,e_D, )S
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
III •
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 CONTRACTORp �. OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
1 &I f 'e'// J.[n 5 ( ) ( )
MAILING ADDRESS: (Cl /_ �/_c oO t 'At cc/ U E. EMAIL:
CONTRACTOR'S LICENSE (D T 10 V /� �^� WAINS
NUMBER: See V/rn, ,,,��y/ ,� ' 7s 38�, NUMBER
ARCHITECT/ENGINEER: For is /` H X 7(/�� ',S 6S 1��U AS PHONE ( ) FAX: ( )
MAILING ADDRESS: 20 7/7 i c O, c / DU silo EMAIL
1.04
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: Li Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair I] Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well I I 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 Xi Above ground Tank Size of Propane Tank: /AO •
❑ Heat Stove )(Cook Stove L) Woodstove --}/Fireplace Insert I 1 Hot Water Tank I Pellet Stove I i Othe
Is this appliance being 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 system components,
including the reserve area.
Square Footage For Office Use Only
Current Proposed Amount
Main Floor Consistency Review: x t 30 -
2NU Floor Base fee: L C.' 7.
Tiro 04_,
3rd 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: $ ` 1:-3 730
Decks
— Receipt Number: ' 'r {
Other Cash/Check Number: ,; r /'
ESTIMATED COST(REQUIRED) Date: �}
•Fair market value of all labor and materials foundation to finish . JJ
Initials: ID -t -1•-
G:\PerrnitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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