HomeMy WebLinkAboutBLD2006-00016 JILDING PERMIT APPLICAAN BLD06-00016
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00016 Received Date: 1/17/2006
SITE ADDRESS: 472 MONTGOMERY LN
PORT LUDLOW, 98365
OWNER: MADELYN CURLL PHONE: 360-437-1328
472 MONTGOMERY LN
PORT LUDLOW WA 983659648
PORT LUDLOW NO 1 AREA 2
SUBDIVISION: Block: 2 Lot: 2
PARCEL NUMBER: 990400202 Section: 9 Township: 28 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 INSTALL 120 GAL HORIZONTAL PROPANE TANK
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION
CODE EDITION: 2003 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: OTHER. SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Propane Tanks/Stoves $51.00 SLE 01/17/06 78918
Total: $51.00
• •
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 #: BLD06-00016 Received Date 1/17/2006
SITE ADDRESS: 472 MONTGOMERY LN Issue Date 1/17/2006
PORT LUDLOW, 98365
APPLICANT: MADELYN CURLL PHONE: 360-437-1328
472 MONTGOMERY LN
PORT LUDLOW WA 983659648
2
SUBDIVISION: PORT LUDLOW NO 1 AREA 2 Block: 2 Lot:
PARCEL NUMBER: 990400202 Section: 9 Township: 28N 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, MADELYN CURLL PHONE: 360-437-1328
if different: 472 MONTGOMERY LN
PORT LUDLOW WA 983659648
PROJECT DESCRIPTION: INSTALL 120 GAL HORIZONTAL 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 1/17/2007.
REQUIRED INSPECTIONS:
cEfre
Tank/Line/Appliance: 7�G� /s4,c1e Ze,GN>'ivi .) /1-/fL'&zeo— W3.(7
FinalApproval: � - r -rra-I 7/%"'‘
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
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ti 1t•IT`r SEPTIC), TANKS,WELL, DRIVEWAYS,SHRUBS&TREES, EXHAUST VENTS, AIR INTAKE,
i1-1B IS T 1BLE SOURCES, RELEVANT WINDOWS AND DOORS.
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f<iON-- psJEFFERSO OUNTY •
1=3r' `� DEPARTMENT OF COMMUNITY DEVELOPMENT
I " '.4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
4kqS, p� www.co.jefferson.wa.us/commdevelopment JAN ] ?O!fir,
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
I1 ) G-AL t-f-br1Zo(iiL- 1n)o - ',1
Tax Parcel n /� Property
Number: qc( o o U d O Pros ze: ° 3 (acre square feet)
Site Address and/or Directions to Property: j ►' ) 61,. ,6 r) a4"y L_/4 VLc' _ ( l L�a_Q ,
►Property Owner(s)of Record: t C L V L U J
Telephone: 11 r
p I � (3)-6' Fax: email:
Mailing Address: -SC-e.,,
Applicant/Agent(if different from owner): ; 1Ct 1h S J t-1' _P rerokr-
Telephone: 3 _S 73_ Fax: . email:
_ /Mailing Address: -)er s / t,Oz�-7 , -T, �,,�T/ i-)Z-0 ei�
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**
❑ 'ddress 11 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
I. 'ropane ❑ Plat Vacation/Alteration**
r 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 desi ct as my n matt rs relatin licatio permit(s).
OWNER SIGNATURE 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
review and any required later inspections.Acce and right of entry to this property shall be requested and shall occur only during regular business
hours.Nal
C
Signature: ij
�.rLG 'IV 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-tr nsferable responsibility for ad ring to n lyomplying with the ESA. The Applicant has read this disclai er an signs and dates it below.
Signature: Ce N Date: f 2_ 3/ �Q c-)
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT • - 1
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 MANUF URED HOME INSTALLER: PHONE: FAX:
4-0.)-1,0---1-21.4--._, 247° (3e6) _3 CS' S e 7S ( )
M1LING ADDRESS: O 2f Y' 'Li c!-i k,-- EMAIL:
CONTRACTOR'S LICENSE �10'/ J� WAINS
NUMBER: S ?(' ` .7 7 (J ( NUMBER
ARCHITECT/ENGINEER: / I' PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ 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 [7 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: �1
[l Underground Tank Above ground Tank Size of Propane Tank: / .)c 6 A . /v G'f i 2
ii Heat Stove ❑ Cook Stove ❑ Woodstove ri Fireplace Insert I i Hot Water Tank ❑ Pellet Stove ❑ 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
Main Floor Consistency Review: t)
5 � 5
2Nu Floor Base fee:
3m Fioor Additional Section: .
Mezzanine: Plan Check fee: 2006 it
Heated Basement State Surcharge fee:
Unheated Basement Pot Water Review fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport TOTAL: $ T)tto • 5 a
40
Decks Receipt Number: .7 is9 I D
Other Cash/Check Number: 34 3 5+
3,i 3 2
ESTIMATED COST(REQUIRED) Date: >+�) to�
•Fair market value of all labor and materials foundation to finish
Initials: SLt,
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc