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Home My WebLink AboutBLD2005-00759 • 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 #: BLD05-00759 Received Date 12/12/2005 SITE ADDRESS: 132 NIP LEE RD Issue Date 12/12/2005 CHIMACUM, 98325 APPLICANT: MICHAEL K GALMUKOFF PHONE: (360) 379-5570 RENEE L GALMUKOFF PO BOX 157 CHIMACUM WA 98325-0157 SUBDIVISION: COLLINS SHORT PLAT 1 Block: Lot: PARCEL NUMBER: 901112024 Section: 11 Township: 29N Range: 01W CONTRACTOR: C H S INC PHONE: (360)732-4585 PO BOX 518 AUBURN WA 98071-0518 Contractor's License CHSIN**9790Z Expires 09/07/2006 OWNER, MICHAEL K GALMUKOFF PHONE: (360) 379-5570 if different: RENEE L GALMUKOFF PO BOX 157 CHIMACUM WA 98325-0157 PROJECT DESCRIPTION: SWAP OUT 250 GAL A/G PROPANE TANK, SAME SIZE AND SAME LOCATION 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 12/12/2006. REQUIRED INSPECTIONS: Tank/Line/Appliance: FinalApproval�— � / (Lie-04 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 1 O/29/1 IJ ILDING PERMIT APPLICA1IN BL Revviewiew T Ty759 ype: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00759 Received Date: 12/12/2005 SITE ADDRESS: 132 NIP LEE RD CHIMACUM, 98325 OWNER: MICHAEL K GALMUKOFF PHONE: (360) 379-5570 RENEE L GALMUKOFF PO BOX 157 CHIMACUM WA 98325-0157 COLLINS SHORT PLAT SUBDIVISION: Block: PARCEL NUMBER: 901112024 Section: 11 Township: 29 N Range: 01 Wt: 1 CONTRACTOR: C H S INC PHONE: (360)732-4585 PO BOX 518 AUBURN WA 98071-0518 Contractor's License CHSIN**9790Z Expires 09/07/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOt SWAP OUT 250 GAL A/G PROPANE TANK, SAME SIZE AND SAME LOCATION 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: CONST TYPE: OTHER: CONST TYPE: GARAGE: SHORELINE: DECK: SETBACK: SEWAGE DISPOSAL: BANK HEIGHT: 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 12/12/05 77495 Total: $49.00 (^ilk JEFFONCOU%NipA DEPARTMENT OF COMMUNITY WILIPaNT: 8 Y E Fr:::. 1 621 Sheridan Street• Port Townsend•Washingn 08368. . 360/379-4450 • 360/379-4451 Fax IsqS, NOS. www.co.jefferson.wa.us/commdevelopment !C 2 2,�,,, I Master Permit Application ^MLA: 1 Project Description(include parate sheets as necessary): Tax Parcel C:,r.., Property Number: 1 L.-)' ' 11 9 -U�� Size: //Z �a�es/square feet)_ Site Address and/or Directions to Property: 1 , L. ° ', p L_r c a �_\'. \ vr\Ctic v,-yr'. �.�.� 14 -c 1 3 2 Property Owner(s)of Record:\1\, t_!•0,r 1 \(- -r e r\r c L � c, yv.v._ 0-. Telephone: 3 E- L,. - 3 l -55-3 0 -fax(le l 13 0 l -a 9 3 6 email: Mailing Address: P DI_ I-ri _\‘ \ vY-,a i_ yr, l�,> -vck 9 i3 3 2,5 Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: 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]** ❑Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑Garage Attached/Detached ❑Special Use(Essential Public Facilities)** ❑Manufactured Home ❑ Boundary Line Adjustment ❑Modular ❑Short Plat-- ❑Commercial* ❑Binding Site Plan** ❑Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** .a'Propane ❑Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑Shoreline Management Substantial Development** ❑ 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: DESIGNATION OF AGENT I hereby designate _to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE . ,l>+ rvvl`, t Date: ) �--) I ) 0 `: 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 attorneys 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 later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours •. Signature: �`,--v Wit' , i Cr'-c, \ -6--- Date: )4 11--3 I 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 responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature:�.�t- L 2,„ . Date: lam-` IJ- / 0.3 G:\PermitCenter\FORMS\DRD FORMS\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: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: C 't '(-\ x ( ) ( ) 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 ❑ Wood Existing: ❑ Sewer CI Addition ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ 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 0 Above ground Tank : "-" _11 qq pf Propane Tank: ZJ U ° -- ❑ Heat Stove ❑ Cook Stove ❑ Woodstove Li Fire ,1ns I El.Hot Water Tank ❑ Pellet Stove Li 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 die prOpiineitank to all property lines,buildings and septic system components, including the reserve area. Square Footage For Office Use Only Current Proposed , .a Amount Main Floor Consistency Review: 2ND Floor Base fee: `� ,( / c. 3n0 Floor Additional Section: Mezzanine: - Plan Check fee: , Heated Basement State Surcharge fee: Unheated Basement - Pot WateF 'fee Other Unheated 911/RdApplt th.fee: ` Garage/Carport TOTAL-- $ < Decks Receipt Number.`' '' Other • Cash/Check Number: ESTIMATED COST(REQUIRED) Date: .Fair market value of all labor and materials foundation to finish ?.1�s.a 6 Initials: 510 G:\PemtitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc NIP LEE RD 10 x 0 z m z a 3 03 m ;a ol In, T m (n O Mo W m