The URL can be used to link to this page

Home My WebLink AboutBLD2006-00269 PUILDING PERMIT APPLICATON BL Revviewiew T Ty269 ype: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00269 Received Date: 5/18/2006 SITE ADDRESS: 381 OLD ANDERSON LAKE RD CHIMACUM, 98325 OWNER: KENNETH J PRZYGOCKI PHONE: 360-732-7491 KAREN M PRZYGOCKI 381 OLD ANDERSON LAKE RD CHIMACUM WA 983259733 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901104009 Section: 10 Township: 29 N Range: 01 W CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883 265 CHIMACUM RD PORT HADLOCK WA 98339 Contractor's License MOUNTP198::,06 Expires 9/26/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI A/G 500 GAL PROP TANK TYPE OF WORK NON SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: 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 le. K<Jr OZ. Type Amount Paid By: Date: Receipt: Approved/Date Propane Tanks/Stoves $51.00 LYK 05/18/06 81232 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 #: BLD06-00269 Received Date 5/18/2006 SITE ADDRESS: 381 OLD ANDERSON LAKE RD Issue Date 5/18/2006 CHIMACUM, 98325 APPLICANT: KENNETH J PRZYGOCKI PHONE: 360-732-7491 KAREN M PRZYGOCKI 381 OLD ANDERSON LAKE RD CHIMACUM WA 983259733 SUBDIVISION: Block: Lot: PARCEL NUMBER: 901104009 Section: 10 Township: 29N Range: 01W CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883 265 CHIMACUM RD PORT HADLOCK WA 98339 Contractor's License MOUNTPI98306 Expires 9/26/2006 OWNER, KENNETH J PRZYGOCKI PHONE: 360-732-7491 if different: KAREN M PRZYGOCKI 381 OLD ANDERSON LAKE RD CHIMACUM WA 983259733 PROJECT DESCRIPTION: A/G 500 GAL PROP 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 5/18/2007. REQUIRED INSPECTIONS: Tank/Line/Appliance: /—j, -Me t7(0-4 /NT L it f . -7DwOk qc.it 6--?f�to FinalApproval: �,-t5 Ob 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 Map Output • IP Page 1 of 1 ArcIMS HTML Viewer Map ~`901104006 r, `�,., „orr2l00002 901104017 `s, 902100001 J1901104015 \. Legend \ e3 'Selected Features Itty\ 901104016 Towns � 'ice% a".) 901104031 ,,,,:V, Carry Snot �� ,•‘. � �.\ � * RiraiCxrs 49 \\ `t fv Road System \ tiI J Parcels-H — \'', Boundaries nJ , Waxy' ---•J j —`�_ 0 C� 9011t74t132 ti 901104007 -�.' Mager pnarided try Jelhrsut Canty Cernrzt Samosa GiS 0 amimmimmi Well FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Thu May 18 09:50:03 2006 • )) .1.1' C L 7 1 Vi---t--r-r'-' MAY 18 2006 r 'i 7gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=4.... 5/18/2006 • ¢,sox co w JEFFERSO'COUNTY ,' ' DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend •Washington 98368 jo 360/379-4450 • G j 2_ 7�� `Sx-INp2p www.co.jeffersonwaus/commdev360/379-4451Faxelopment 3 I ,� 1 O flli1 Master Permit Application MLA: 2CC()Ok_ Project Description (include separate sheets as necessary): ,_,c G.- e .2,•,- - -7 / g---70,.--e-- / .,,-!--e:- Property Tax Parcel Number: �G%/U4�G'G 9 Size: l J �- (acres/square feet) Site Address and/or Directions to Property: 5, /�� iti771t��S�.J /,, ,, - .C��7 Property Owner(s)of Record: �E� ¢ 9,- E') ��j/le=5 e Telephone: .:57 -•& 7-��- 7 V2,1 Fax: email: /JiL;›,2,e.:c"---2 at)C.9 -7 Mailing Address: -s"'. ,--7 T �� 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** MAY 1 8 2006 ❑ Change of Use ❑ Long Plat** ❑yddress ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ropane ❑ 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 toprovide-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 ry to this property shall be requested and shall occur only during regular business hours. _ Si 'nature: Date: c 5 •�� The acio wi I 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 ar ' mp ilit ance with the Jeffers,on County development code.The Applicant acknowledges that he,she or it holds individual and non- transfer responsibili ering to and cbjnplyin the ESA. The Applicant has read this disclaimer aZ and cis es it below. Signs ure: Date: �/S� c' ' -- 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 the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED ME 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: ❑ New ❑ Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank Height: ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: ❑ 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 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: ❑ Underground Tank E Above ground Tank Size of Propane Tank: y C, 4--:i9l S ❑ Heat Stove ❑ Cook Stove ❑ Woodstove >it Fireplace Insert ❑ 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: ` Other Heated Base fee: _— Mezzanine Additional Section: Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL ,Co, Decks 911/Rd Approach fee: Other TOTAL: $ Receipt Number: 9 I a3`1 Cash/Check Number: --1-7 ESTIMATED COST(REQUIRED) Date: �11210(0 .Fair market value of all labor and materials foundation to finish Initials: ,�, ..� G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc ��