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HomeMy WebLinkAboutBLD2005-00647 • 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 #: BLD05-00647 Received Date 10/6/2005 SITE ADDRESS: 4415 LARSON LAKE RD Issue Date 10/6/2005 CHIMACUM, 98325 APPLICANT: GARY W USA PHONE: DONNA G USA 17 NORTH LAKE AVE THIRD LAKE IL 60030 20 SUBDIVISION: MT TOWNSEND VISTA Block: Lot: PARCEL NUMBER: 801105014 Section: 10 Township: 28N Range: 01W CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797 10853 RHODY DR PORT HADLOCK WA 98339 Contractor's License SUNSHP*077QP Expires 11/17/2006 OWNER, GARY W USA PHONE: if different: DONNA G USA 17 NORTH LAKE AVE THIRD LAKE IL 60030 PROJECT DESCRIPTION: NO MLA REQ'D -A/G 250 GALLON PROPANE TANK 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 10/6/2006. REQUIRED INSPECTIONS: Tank/Line/Appliance: ?RvPANL -rANk, 514. rCG64 Otrr �I27 d$ l FinalApproval: 7K }or- }► r1a-1 1/y7706- 0' �1 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 10/29/19E 0UILDING PERMIT APPLICAtN BLRDOe 00647 Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00647 Received Date: 10/6/2005 SITE ADDRESS: 44.5 LARSON LAKE RD CHIMACUM, 98325 OWNER: GARY W USA PHONE: DONNA G USA 17 NORTH LAKE AVE THIRD LAKE IL 60030 MT TOWNSEND VISTA SUBDIVISION: Block: Lot: 20 PARCEL NUMBER: 801105014 Section: 10 Township: 28 N Range: 01 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 NO MLA REQ'D - A/G 250 GALLON PROPANE TANK 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 CJZ 10/06/05 77025 Total: $49.00 0 T6' V ON 4�y�' c06, JEFFERS COUNTY E rz, ' S,� DEPARTMENT OF COMMUNITY DEVELOPMENT 'W' "4 621 Sheridan Street • Port Townsend•Washington 98368 360/379-4450 • 360/379-4451 Fax ' .- 1.0, (cp'$ www.co.jefferson.wa.us/commdevelopment BIND It:ccpqnN rOUNT' r Master Permit Application MLA: • Project Description(include separate sheets as necessary): P2JFAkc .TAuje' Si....? )7c// -Oc.t T Tax Parcel Property Number: S 0) / 0 S 0/y Size: w.3 Ac,i,,s (acres/square feet) ` Site Address and/or Directions to Property: 'ail .5 L/12 S.:4 LAi r AO C.H,.nit cam,.r) 1 /Lb'4, 1�3 L s- Property Owner(s)of Record: ( ay 1.4. t!l S'A ✓-1 m 3 /O:j..,+2,i C ci SO! Telephone: $'-i 1- Z L 3- >y?/ Fax: email: ,d t.s 4 .1. c' Cann c 2_57.h r Mailing Address: 17 Al. L % '. /t Vs. , Ta,n© L.Ale' , t C. 6 o03 0 Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) fti'iguilding ❑ Variance(Minor,Major or Reasonable Economic Use) 1 I Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification [l Garage Attached/Detached Li Special Use(Essential Public Facilities)** [1 Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** 1.1 Commercial* ❑ Binding Site Plan** 11 Change of Use LI Long Plat** ❑ Address 1 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** M4'ropane ❑ Plat Vacation/Alteration** ❑ Allowed"Yes"Use Consistency Analysis 11 Shoreline Master Program Exemption/Permit Revisions** 0 Stormwater Management ❑ Shoreline Management Substantial Development** 1 Site Plan Approval Advance Determination(SPAAD)* LI Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑ Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment Ii 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: n DESIGNATION OF AGENT /C I hereby designate /a) Y CA a_Tc:-A to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE ""`, AV �- L Date: c9 3 L` • 0 S- t • 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 oT 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. l / Signature: "`'1 �+/ 21,, - -- Date: - -3o ' D 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 /l�r�sponsib�ity ffor appering to and complying with the ESA. The Applicant has read this disclaimerc and signs and dates it below. Signature: � ( � Date: " 30 0 C:\Documents and Settings\mochil\Desktop\Master Permit 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. Signature: _ c 7_.ry 2 - Date: / C - 0 .5-- 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: LI New [_I Wood Existing: I I Sewer Addition I I Steel Proposed: Bank 11 Community System Alteration/Remodel L I Concrete Total: Height: ❑ Individual System I Repair Li Masonry SEP Permit# I Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: I i Private well LI Two Party Type of Heat: Proposed: LI Public Total: Name of System: If this is a Commercial Prolect 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 A pliance Installation ermit mark all items below that a 1 : I Underground Tank Above ground TanI i' Size of Propane Tank: 2 5 U L fa&, I Heat Stove I Cook Stove Woodstove I Fireplace Insert Hot Water Tank I Pellet Stove 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. Square Footage For Office Use Only Current Proposed Amount V Main Floor Consistency Review: v LJ 2Nu Floor Base fee: ate 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 TOTAL: $ 5. Decks Receipt Number: Other Cash/Check Number. �ll ESTIMATED COST(REQUIRED) Date: b L .Fair market value of all labor and materials foundation to finish 1 0/ Initials: (::\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc C'.2Z54 dSp ),-"v9 A - I,/osoit080 ,,,vtl " c2i-$ •Nn 'L"')dcuif-ID ''Cl'' vyr%7 Recvt'7 s'h/7 -r.10 NItiMc P L 9I?yd3V1 f d z, 9 ,tills?,ti7 c.1� 1 L 1-- C. ,I I I v s w Si/ 0 m ''N\\\ W IJ i v s c ^ -, 14— ,?-‘?:--? _______________} j7 c t- Cam, 3 o C. S " y '� C `p t c I.. V6 ( C , C c1 c 1 A (.-3, _ - - _ , 0 fi