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Home My WebLink AboutBLD2005-00622 BUILDING PERMIT APPLICA B RDOe 006pe22 N Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00622 Received Date: 9/26/2005 SITE ADDRESS: 190 E BEACH RD NORDLAND, 98358 OWNER: SUSAN G SIMMONDS PHONE: 190 E BEACH RD NORDLAND WA 983589622 HILLER SHORT PLAT SUBDIVISION: Block: Lot: PARCEL NUMBER: 021333030 Section: 33 Township: 30 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 DESCRIPTIOr NO MLA REQ'D - A/G 120 GALLON PROPANE TANK , GAS PIP & HEAT STOVE TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: 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 CJZ 09/26/05 77010 Total: $49.00 0 • 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 #: BLD05-00622 Received Date 9/26/2005 SITE ADDRESS: 190 E BEACH RD Issue Date 9/26/2005 NORDLAND, 98358 APPLICANT: SUSAN G SIMMONDS PHONE: 190 E BEACH RD NORDLAND WA 983589622 SUBDIVISION: HILLER SHORT PLAT Block: Lot: PARCEL NUMBER: 021333030 Section: 33 Township: 30N 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, SUSAN G SIMMONDS PHONE: if different: 190 E BEACH RD NORDLAND WA 983589622 PROJECT DESCRIPTION: NO MLA REQ'D -A/G 120 GALLON PROPANE TANK , GAS PIP & HEAT 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 9/26/2006. REQUIRED INSPECTIONS: Tank/Line/Appliance: /0 S `O5 FinalApprovalL 1b'5-D...5—' 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 Sep 26 05 11 : 34a Let 1 -360-385-5875 p. 2_ • SITE VISIT REPORT (PLOT PLAN) JOBoa DATE : `�11z JoS CONTACT: ADDRESS 19 O E F,:,c Ac \ av-oZ.al3o PHONE #: DIRECTIONS FAX #: Email PLANNER: 1 1 $ $20 NO H L V 0wiii° co . JEFFERSON SUNTY • • ` ,i DEPARTMENT OF COMMUNITY DEVELOPMENT c �n5 621 Sheridan Street • Port Townsend •Washington 98368 $�P �,U UU 360/379-4450 • 360/379-4451 Fax �.�,�NG�O� www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Project Description(include separate sheets as necessary): Pl.i, Tax Parcel Property Number: 0 2 I 3 3 3 0 Size: 3 Q (acres/square feet) Site Address and/or Directions to Property: psi b E. Q e.--c_k___ IJ (-y,,9 (Jc Property Owner(s)of Record: '- T S S1-1.-f— s5;ill rn or 0.S ` Telephone: 385 2//v Fax: email: Mailing Address: I �1 0 L • d e e,../, N 612-o-i n wr/. Applicant/Agent(if different from owner): U.rill/i h E P 2 a p.74 h e Telephone: 3 8 S- S 7 5 7 Fax: email: Mailing Address: /O S3 Rh oC n r. P i Net D<-ou, What kind of Permit?(Check each box that applies) ❑ Building ❑Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit ❑ 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)** ❑Manufactured Home 0 Boundary Line Adjustment 0 Modular ❑ Short Plat** ❑Commercial* ❑ Binding Site Plan** ❑Change of Use ❑ Long Plat** 0 Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** Propane ❑ Plat Vacation/Alteration** AI owed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline,Management Substantial Development** 0 Site Plan Approval Advance Determination(SPAAD)* ❑ 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: • DESIGN ION OF AGENT I he b esi ct as my n matt rs relatin licatio ermit(s). TORE e: 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 gigreview and any required later inspections.Access and right of entry to this property shall be r quested and shall occur only during regular business hours. Signature: 7( /7 /I -Z' Date: 7� . _— C 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 NI `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 bility for ad edng to and complying with the ESA. The Applicant has read this disclaimer and sign g dates it below. Signature: 7c i�re 1, r NDate: 7� , ,,/c)DS G:\PerrnitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • OWNER BUILDER STATEMENT • ne 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 iey 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 0 Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System O Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# O Demolition CI Other:___ _ Bedrooms: Water Supply: Existing: Setback: ❑ Private well 0 Two Party Type of Heat: Proposed: Li 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: 0 Underground Tank 'Above ground Tank Size of Propane Tank: / 2_o ,r(Heat Stove I I Cook Stove CI Woodstove ❑ Fireplace Insert Li Hot Water Tank C I Pellet Stove Other /r--rt2 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: 5° 2loor Base fee: 4G 31d 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: $ Decks Receipt Number: �D I O Other Cash/Check Number: 3 33 ESTIMATED COST(REQUIRED) Date: q• ( /0 .Fair market value of all labor and materials foundation to finish Initials: \PermitCenter\FORMS\DRD FORMS\Master Nentut Application 7-8-04.doc