HomeMy WebLinkAboutBLD2006-00184 tILDING PERMIT APPLICA•N BLD06-00184
Review
Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD06-00184 Received Date: 4/18/2006
SITE ADDRESS: 113 DENA LN
CHIMACUM, 98325
OWNER: CRAIG VAN NESS PHONE: (360) 732-0990
MARIA M VAN NESS
2096 ANDERSON LAKE RD
CHIMACUM WA 98325-9761 BISHOP HEIGHTS DIV II
SUBDIVISION: Block: Lot: 6+
PARCEL NUMBER: 933500006 Section: 35 Township: 29 N Range: 01 W
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 DESCRIPTION INSTALL A/G 250 GAL PROPANE TANK, GAS PIPING AND COOK
STOVE
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 2003 AMYL: 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 By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $51.00 KAS 04/18/06 81076
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 #: BLD06-00184 Received Date 4/18/2006
SITE ADDRESS: 113 DENA LN Issue Date 4/18/2006
CHIMACUM, 98325
APPLICANT: CRAIG VAN NESS PHONE: (360) 732-0990
MARIA M VAN NESS
2096 ANDERSON LAKE RD
CHIMACUM WA 98325-9761 6+
SUBDIVISION: BISHOP HEIGHTS DIV II Block: Lot:
PARCEL NUMBER: 933500006 Section: 35 Township: 29N Ranqe: 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, CRAIG VAN NESS PHONE: (360) 732-0990
if different: MARIA M VAN NESS
2096 ANDERSON LAKE RD
CHIMACUM WA 98325-9761
PROJECT DESCRIPTION: INSTALL A/G 250 GAL PROPANE TANK, GAS PIPING AND COOK
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 04/18/2007.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:
FinalApproval: 319)01
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£
rik64.
oNJEFFERSO.OUNTY •
DEPARTMENT OF COMMUNITY DEVELOPMENT ,
621 Sheridan Street • Port Towns•And ..Washington 98368
360/379-4450 • 360/379-4451 Fax
41N�qsp' www.co.jefferson.wa.us/commdevelopment
Master Permit Application I'^I MLA:
Project Description (include separate sheets as necessary): JEff ERSQN CIIUNII IM
7ki.; I\Le_ T i'I t�c�
Property wC2t-
Tax Parcel Number: 3e3 S(jam r_) (� Size: Z , 5 (acres/square feet)
Site Address and/or Directions to Property: ( j 3 DEt( H N-, Pt-C, v•.‘
Property Owner(s)of Record:
Telephone: 2,( a -1l3 Z - U Fax: email:
Mailing Address: 2.0`k L- ti D it ?Svr. L c ?.7
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**
.X 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 Date:
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 attorney'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 inspectiops.Access and right of entry to this property shall be requested and shall occur only during regular business
hours. I J
Signature: ( V '-�- Date: t - r U6-2
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 r sponsibility for ad erin to an complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: c, Date: 1tP12 \ U b
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
• 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 e General Contractor for the proposed project.
b
Signature: k. Date: 1 \" , '
'
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: f.� S\�) � NUMBER
A cstt£Ct/EtietNEER: PHONE ( ) FAX: (
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank Height: ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well 1.1 Two Party
Type of Heat: Proposed: ❑ Public
Total: Name of System:
If this is a Commercial Protect 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:
I Underground Tank J 1 Above ground Tank Size of Propane Tank:
❑ Heat Stove l 1 Cook Stove I] Woodstove 1 Fireplace Insert I 1 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 Current Proposed For Office Use Only Amount Revision
Main Floor Heated EH Bld App Review:
2nd Floor Heated Consistency Review: nG is
Other Heated It Base fee:
Mezzanine Additional Section:
Heated Basement p4 Plan Check fee:
Unheated Basement JEFf FRSDt COUNTY '. State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
11 (0. 50
Decks 911/Rd Approach fee:
Other TOTAL: $ 'f66 I)
Receipt Number: D I D" ) (
Cash/Check Number: ( OCQ
ESTIMATED COST(REQUIRED) Date:.Fair market value of all labor and materials foundation to finish �y O(O fp
Initials:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
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