HomeMy WebLinkAboutBLD2005-00693lown—
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 #: BLD05-00693 Received Date 11/3/2005
SITE ADDRESS: 2063 THORNDYKE RD Issue Date 11/3/2005
PORT LUDLOW, 98365
APPLICANT: ERIK B NORDSTROM PHONE:
JULIE NORDSTROM
PO BOX 716
MEDINA WA 980390716 T15 +
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 721174008 Section: 17 Township: 27N 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, ERIK B NORDSTROM PHONE:
if different: JULIE NORDSTROM
PO BOX 716
MEDINA WA 980390716
PROJECT DESCRIPTION: Change out U/G 500 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 11/3/2006.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: VRCspANL. 'TANI< 4 EX-rER Ion L b,L II/b)/ASr
FinalApproval: (D 1' -rcir v a-I I 1 Dl(OS
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£
•
BUILDING PERMIT APPLICA•N BL v
Reviewiew T Ty693
ype:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD05-00693 Received Date: 11/3/2005
SITE ADDRESS: 2063 THORNDYKE RD
PORT LUDLOW, 98365
OWNER: ERIK B NORDSTROM PHONE:
JULIE NORDSTROM
PO BOX 716
MEDINA WA 980390716
SUBDIVISION: Block: Lot: T15 +
PARCEL NUMBER: 721174008 Section: 17 Township: 27 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 DESCRIPTION Change out U/G 500 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 11/03/05 77265
Total: $49.00
11/01/2005 18:00 3603794451 JEFF CO DOD PAGE 02/02
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•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 CO TRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
P/1,c-?.a (3 ) )1.i.3 7s 7 ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE ` Ai,r s.6 Q 77 Q(3 WAINS
NUMBER: J NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
0 New ❑ Wood Existing: _ ❑ Sewer
0 Addition 0 Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
0 Repair ❑ Masonry SEP Permit#
0 Demolition 0 Other: Bedrooms: Water Supply:
Existing: — Setback:
Type of Heat: Proposed: ❑ Private well ❑ Two Party
Total: 0 Public
— 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 ❑ Above ground Tank Size of Propane Tank: ,S Q 0 ('fir is
Heat Stove ❑ Cook Stove L! Woodstove Li Fireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 Other
Is this appliance being installed in a Manufactured I 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:
2ND Floor Base fee:
3`a Floor Additional Section:
Mezzanine: T Plan Check fee:
Heated Basement State Surcharge fee: .
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport — _--
TOTAL: $
CDecks x ----_—
_ Receipt Number: ►11 Q(P�
Other Cash/Check Number:
33-15
ESTIMATED COST(REQUIRED) Date: /
.Fair market value of all labor and materials foundation to finish /( /3/4S-
Initials: fill
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�s � o�� JEFFERSO _ __
` DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Streets Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�q,..: .y www.co.jefferson.wa.us/commlie1 elopr ePit)05
Master Permit Application L0Pt,aErlY MLA:
Project Description(include separate sheets as necessary): .. •
SOU Gt _ G. /c ..
Tax Parcel n( Property
Number: �l �� 0 Size: (acres/square feet)
Site Address and/or Directions to Property: Z c ,3 ^f /< / , /9 - u1s—
Property Owner(s)of Record:c/� /J JTRJ M
Telephone: Fax: email:
Mailing Address: )4O &0Z 7/6 ' �eQ i,t/4 , p//}, / el"0 37'
Applicant/Agent(if different from owner): ,S 'A '7 41- st_ _/Telephone: 3 kf f .S 7 ci 7 Fax: email:
Mailing Address: /nor 5"3 ,' i 2 '• pi; )y c.it , CJ e9 .
What kind of Permit?(Check each box that applies)
1 I Building ❑Variance(Minor, Major or Reasonable Economic Use)
0 Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
0 Single Family 0 Discretionary"D"or Unnamed Use Classification
0 Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
0 Manufactured Home LI Boundary Line Adjustment
0 Modular Li Short Plat**
0 Commercial* ❑ Binding Site Plan**
❑ Change of Use 0 Long Plat**
❑Address 11 Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments**
ropane ❑ Plat Vacation/Alteration**
,•.,.,tved"Yes" Use Consistency Analysis LI Shoreline Master Program Exemption/Permit Revisions**
L Stormwater Management U Shoreline Management Substantial Development**
i Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline F 1anagement Variance
LI Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* I i Jefferson County Shoreline Master Program Amendment
Li 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 ht desi ct as my n matt rs relatin�y licatio ermit(s).
Cfl -TURE 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 its 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 I er inspections.Access and right of entry to this property shall be requested and shall occur only during regular business
. �J //� ( ¼1Y4- )Signature: /� �t Qom, �/I r/ It'-.mot Date:
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 respon bility for adhering to and mplying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: /9p I(c Date:
111
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