HomeMy WebLinkAboutBLD2007-00005 • •
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 #: BLD07-00005 Received Date 1/11/2007
SITE ADDRESS: 211 KELLY RD Issue Date 1/11/2007
BRINNON, 98320
APPLICANT: SYDNEY D DALY PHONE: 253-857-6533
KATHLEEN L DALY
PO BOX 1095
OLALLA WA 983591095 16
SUBDIVISION: OLYMPIC CANAL ADDITION 4 Block: 23 Lot:
PARCEL NUMBER: 981002316 Section: 16 Township: 25N Range: 02W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2008
OWNER, SYDNEY D DALY PHONE: 253-857-6533
if different: KATHLEEN L DALY
PO BOX 1095
OLALLA WA 983591095
PROJECT DESCRIPTION: NO MLA REQ'D 250 GALLON PROPANE TANK SWAPOUT SAME
SIZE 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 1/11/2008.
REQUIRED INSPECTIONS:
r
Tank/Line/Appliance:
FinalApproval'` \ \ -1..-1,-07
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
07-00005
0UILDING PERMIT APPLICATION BL Review
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00005 Received Date: 1/11/2007
SITE ADDRESS: 211 KELLY RD
BRINNON, 98320
OWNER: SYDNEY D DALY PHONE: 253-857-6533
KATHLEEN L DALY
PO BOX 1095
OLALLA WA 983591095 OLYMPIC CANAL ADDITION 4
SUBDIVISION: Block: 23 Lot: 16
PARCEL NUMBER: 981002316 Section: 16 Township: 25 N Range: 02 W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2008
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI` NO MLA REQ'D 250 GALLON PROPANE TANK SWAPOUT SAME
SIZE 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: 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
Permit $51.00 DJK 01/11/07 87090
Total: $51.00
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360/379-4450 • 360/379-4451 Fax ,)�A�
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Master Permit Application A: \r b IN1 y1. b,.-0
Project Description (include separate sheets as necessary): ek.\\*‘\6\1.)- 5 ' I y P c . . :/
Tax Parcel Property
Number: ''-/ c: I !'(, .,) ! (. Size: , ) `/ (acres/square feet)
Site Address and/or Directions to Property: .,,. ty ir...,: /// ,i ,j / h N , c--,L G,. A)
Property Owner(s)of Record: . ,,,,, -,, `.. , • • 1.) /-y
Telephone: ) .. ' : S 7-C- C jy Fax: email:
Mailing Address: ' /-2,7 , /i//%. 3 i
Applicant/Agent(if different from owner):
Telephone: Fax: __ email:
Mailing Address:
hat kind of Permit?(Check each box that applies)
d Building i Variance(Minor, Major or Reasonable Economic Use)
Demolition Permit i Conditional Use[C(a), C(d), or Cj**
i Single Family I Discretionary"D"or Unnamed Use Classification
i Garage Attached/Detached I Special Use(Essential Public Facilities)**
i Manufactured Home i Boundary Line Adjustment
i Modular i Short Plat**
i Commercial* I Binding Site Plan**
i Change of Use i Long Plat**
}Address Road Approach Planned Rural Residential Development(PRRD)/Amendments**
ropane S avr�e S i ye Sa me 1-o c a} o v� I Plat Vacation/Alteration**
i Allowed"Yes"Use Consistency Analysis Shoreline Master Program Exemption/Permit Revisions**
i Stormwater Management Shoreline Management Substantial Development**
Site Plan Approval Advance Determination (SPAAD)* I Shoreline Management Variance
i Temporary Use Comprehensive Plan/UDC/Land Use District Map Amendment
i Wireless Telecommunication* I 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 inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the application that he or she wants prior notice.
Signature: " 'J t_ Date:
The action or actions Applicant will undertake as a result of the issuance of th s 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 disclaim r and7signs and dates it below.
Signature: _ 44--) / Date:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.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 HOME INSTALLER: PHONE: FAX:
Cl-\ 5 (25 ) 3S — 7 20 ( )
MAILING ADDRESS: `p, to-)e 5I'g la (L,_ _ l A. EMAIL:
CONTRACTOR'S LICENSE �r r `^'�w�` ACT WAINS
NUMBER: CA S- 4K* et-pi b 7 NUMBER
ARCHITECT/ENGINEER: ( V PHONE
( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New ❑ Wood Existing: 0 Sewer
Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: 0 Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well 1 i 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 f° ,I Above ground Tank Size of Propane Tank: (150 ?ill1 Z1rhe Site. Same
i Heat Stove i Cook_ Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet StoJ6 i Other t.Vcaho k
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:
2"d 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
Decks 911/Rd Approach fee:
Other TOTAL: $
51 , 00
Receipt Number: S')Vq D
CCash/ eck Number:
ESTIMATED COST(REQUIRED) Date: 1 — 11 -TT
•Fair market value of all labor and materials foundation to finish
Initials: r-N V......„
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-142006.doc