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HomeMy WebLinkAboutBLD2005-00452 • . 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 #: BLD05-00452 Received Date 7/12/2005 SITE ADDRESS: 111 WERNER RD Issue Date 7/12/2005 PORT LUDLOW, 98365 APPLICANT: ELKE I GOBRIGHT PHONE: (206) 542-7710 C/O KAREN NICKLE 24301 FIRDALE AVE EDMONDS WA 98020 + SUBDIVISION: Block: Lot: PARCEL NUMBER: 821081033 Section: 8 Township: 28N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: OWNER, ELKE I GOBRIGHT PHONE: (206) 542-7710 if different: C/O KAREN NICKLE 24301 FIRDALE AVE EDMONDS WA 98020 PROJECT DESCRIPTION: INSTALL WOOD 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 D TE IN471r06. REQUIRED INSPECTIONS: Tank/Line/Appliance: n \ 0')\\ FinalApproval: 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� ��cytSON C•O� ,. ,,. _ 5 i JEFFERSOIS JUNTY A DEPARTMENT OF COMMUNITY DEVELOPMENT 1-4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax qS, Nasp www.co.jefferson.wa.us/commdevelopment _� ON COMP/ OiJr Master Permit Application _ MLA: Project Description (inc ude sepfra,�tte,sheets as necessary):U ' /t i i ( �]L V6 Tax Parcel Property Number: g 2 I — O p O I — Y g3 Size: ( 'square feet) Site Address and/or Directions to Property: // / (, /61 jip Q _ Property Owner(s)of Record: f%, - L-unif)(4 l� ll- Z. (-7apzr, r• Telephone: p(1, yZ'-7- /O Fax: Mailing Address: C v - email: /�, Applicant/Agent(if different from owner): Telephone: Fax: Mailing Address: email: What kind of Permit?(Check each box that applies) Building ❑Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit _ se[C(a), C(d),or C]** ❑ Single Family , ,� ( ❑ Garage Attached/Detached i L (; ireti. "D"or Unnamed Use Classification ❑Manufactured Home f I = Essential Public Facilities)** ❑ Modular I i ❑ Boun I e Adjustment ❑ Commercial* JUL 1 2 2horl Plat ❑ Change of Use ❑ Long Plat Indin Si Plan** ❑Address ❑ Road Approach ** p nned Ru al Residential Development(PRRD)/Amendments ❑ Propane — ifJ lat Vacati• /Alteration** 41lowed"Yes"Use Consistency Analysis 3tormwater Management -•���-shoreline Master Program Exemption/Permit Revisions** ❑ Shoreline Management Substantial Development** Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance emporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment Vireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment orest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference **Requires a Pre-Application Ise identify any other local, state or federal permits required for this proposal, if known:Conference DESIGNATION OF AGENT ;by designate to act as my agent in matters relating to this application for permit(s). SIGNATURE Date: s-ing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of 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 suit in this permit being null and void. agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and 3s which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application nd any required later inspe tions.Aiccess and right of entry to this property shall be requested and shall occur only during regular business /t7 // /(e ,• • ,ltd)/7,,,7--14 f . Date: / . n or actions Applicant will un'ofertake as a result of the issuance of this permit may negatively impact upon one or more threatened or ed species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the red Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your yen i u are in compli nce wit the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual ins b es nsi '' for •ring o and co yi/sg with the ESA. The Applicant has read this disclaimer and signs and dates it below. Date: i. er\FORMS\DRD FORMS\Master Pemut Application 7-8-04.doc • 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. n S �� �/ G C Or7�' `� / Date: C Signature: � �J , / -- FAX: CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: UMBER ARCHITECT/ENGINEER: © r r � , 11-5) .-ONE ( ) FAX: ( ) MAILING ADDRESS: 4r _ Ef vIAIL ��qA� Shoreline: Type of Sewage Disposal: Project Type: Frame Type: v v Batl?rodrrils ❑ New 0 Wood Existing: 17 Sewer 0 Steel Proposed: - Bank ❑ Community System ❑ Addition Total: Height: i 1 Individual System ❑ Alteration/Remodel ❑ Concrete -- ____ # ❑ Repair ❑ Masonry SEPer Permit# Other: Bedrooms: ❑ Demolitier. �� Existing: Setback: I I Private well I i Two Party Proposed: [1 Public Type of Heat: Total: Name of System: If this is a Commercial Proiect you must answer the following: Number of ADA Parking Spaces: Number of Parking Spaces: Current: Proposed: Number of occupants(includes owners,tenants,employees,etc) Current Proposed Type Occupancy: IBC T e 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 I 1 Above ground Tank Size of Propane Tank: O Heat Stove I I Cook Stove y Woodstove U Fireplace Insert I7 Hot Water Tank L1 Pellet Stove I I Other 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. I Square Footage For Office Use Only Amount l Current Proposed Main Floor Consistency Review: e--"--' 2""Floor Base fee: 11-g _0° 3`°Floor Additional Section: I-.. Mezzanine: Plan Check fee: ./----'' Heated Basement State Surcharge fee: /---- Unheated Basement Pot Water Review fee: //_ Other Unheated 911/Rd Approach fee: / / Garage/Carport TOTAL: $ 4(1 .00 Decks Receipt Number: `-1b ) /c Other Cash/Check Number: ESTIMATED COST(REQUIRED) Date: t G�j .Fair market value of all labor and materials foundation to finish Initials: 10 I+ G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-I4.doc