HomeMy WebLinkAboutBLD2007-00043 WILDING PERMIT APPLICA1N BLRDOe 0000we43
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00043 Received Date: 2/8/2007
SITE ADDRESS: 1627 THORNDYKE RD
PORT LUDLOW, 98365
OWNER: BLAKE W NORDSTROM PHONE:
MOLLY NORDSTROM
500 PINE ST FL 6
SEATTLE WA 981011742
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 721174034 Section: 17 Township: 27 N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP`077QP Expires 11/17/2008
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOt NO MLA REQ'D GAS PIPING TO NEW GENERATOR
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:
OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $102.00 DJK 02/08/07 137213
Total: $102.00
• I
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 #: BLD07-00043 Received Date 2/8/2007
SITE ADDRESS: 1627 THORNDYKE RD Issue Date 2/8/2007
PORT LUDLOW, 98365
APPLICANT: BLAKE W NORDSTROM PHONE:
MOLLY NORDSTROM
500 PINE ST FL 6
SEATTLE WA 981011742
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 721174034 Section: 17 Township: 27N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2008
OWNER, BLAKE W NORDSTROM PHONE:
if different: MOLLY NORDSTROM
500 PINE ST FL 6
SEATTLE WA 981011742
PROJECT DESCRIPTION: NO MLA REQ'D GAS PIPING TO NEW GENERATOR
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 2/8/2008.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: 1?Op,4 u-F L.IN& EXTA Pit 3/6,a7,
FinalApproval: ai< /o/zn p8 ff
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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SITE VISIT REPORT
(PLOT PLAN)
JOB kb.(Z,I) S?V .n l3`YJ\Z-i, DATE : 'J3 0 (Y
CONTACT:
ADDRESS I (pal -T}JsoR,N-z:,,,\uk._ PHONE #: .
DIRECTIONS FAX #:
Email
) a( N SUMS S PLANNER: �, L
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FEB 082007
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DEPARTMENT OF COMMUNITY DEVELOPMENT
i44,-' 'V 621 Sheridan Street • Port Townsend •Washington 98368 0 8 707
360/379-4450 • 360/379-4451 Fax �',
�q�, p� www.co.jefferson.wa.us/commdevelopment i•
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Master Permit Application MLA: 'V a \Y\LA-\L .
Project Description(include separate sheets as necessary):
Tax Parcel / / CI Property
Number: ' /,7L/ C' D Size: (acres/square feet)
Site Address and/or Directions to Property: ]G a 7 ) 7--0-r ,,,,9--,. (r�1/- I-km L...„jt,,
Property Owner(s)of Record: R z-fi lz c / th L: 1L-L L/ O 12-n_5 o AAA
Telephone: Fax: email: .
Mailing Address: ``f O y 7 ,1 i) 4 I . A! L ._S .�Ct , L,1,7c:
Appricant/Anent(if different from owner): Vi.r r) 71/nl P ✓a.P l7I?!A-A)42
Telephone: ,3 O.S S 75' 7 Fax: ,? R,5--58 ?S email: /N FO�a ,fl f1/fy//7P�i'hie)/`Rn1Q •
Mailing Address: / O 'S 7 /2h%o y ,t�/Z, PIT II n7,C.a c/c CA)4- c�� . 3 9 cow
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]**
0 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(PRRDYAmendments**
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:
/7 �BJESIGNATIO PAGENT ---, I
i he oy a ai ct a .gent i Ott- ii • : + is . ion er (s).
w T E i ate: .
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,isne 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 inspec' ns.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
(. Signature -' 2/ , Date: "-1,r
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.
,..,7 Signature:`‘ Date: i.
G:\PemutCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 51)
A.:44
CEIK FA
1t ) 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:
I['ii01111i, Ill '
GENtRAL ONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
Su/1sh,A1t ,°2 0p4nl € (360) ? 8S-s797 (366) 383- 5S7S
MAILING ADDRESS: / 0 4 `- ? f� N-o 0 y 01 EMAIL: I n Fo JU 1 ctfrn e PRapeel-rte . coM
CONTRACTORS LICENSE �^ \ WAINS
NUMBER: Jut N s 10O 7K 07 76z P NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New 0 Wood Existing: ❑ Sewer
O Addition 0 Steel Proposed: Bank 0 Community System
n Alteration/Remodel ❑ Concrete Total: Height: 0 Individual System
❑ Repair 0 Masonry SEP Permit#
O 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: xis 7„J G 7291.71 —
❑ Underground Tank ❑ Above ground Tank Size of Propane Tank:_ ,
❑ Heat Stove ❑ Cook Stove ❑ Woodstove Li Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove X.Other (rJ Pi
Is this appliance being installed In a Manufactured/Mobile Home? Yes /(N) / 0l�u� 4Pn e4p`tlL1>'7 LP
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 . w� ;t ' iii , g r *°V {
Current Proposed :. a' *ail tiI , ,
Main Floor Consistency 12eyi (Ns - y 1 "
2Nu Floor Base fee: I • t '
3f0 Floor Additional Section:
Mezzanine: Plan Checklee
~Heated Basement ''-State Surcharge fee. „�
�` 1
Unheated Basement Pot Water Review fee: t��h� � . '�';
J�L1'1iY� ��
�i '�ti s
Other Unheated 911/RdApproach fee : w ;� w ed', ' ' .1
Garage/Carport TOTAL: $ "
Decks
• ..R ipt Number: ;1,4 t: ,{,,-L
Other sh/Check Number: _ n 9` �a
ESTIMATED COST(REQUIRED) Date: ;` dwa;
•Fair market value of all labor and materials foundation to finish „4. y '-V .,.
Initials: `` ' '
G:\PerrnitCenter\FORMS\DRD FORMS\Master Pemvt Application 7-8-04.doc