HomeMy WebLinkAboutBLD2007-00311 • •
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 #: BLD07-00311 Received Date 6/13/2007
SITE ADDRESS: 200 GRIFFITHS POINT RD Issue Date 6/13/2007
NORDLAND, 98358
APPLICANT: KEITH L BROSSARD PHONE: 360-344-4110
DAWN A BROSSARD
200 GRIFFITH POINT RD
NORDLAND WA 983589624
SUBDIVISION: NORDLAND Block: Lot:
PARCEL NUMBER: 976201903 Section: 32 Township: 30N Range: 01 E
CONTRACTOR: DOUBLED ELECTRICAL INC PHONE: 360-385-1130
PO BOX 957
PORT HADLOCK WA 98339 3B l 385
Contractor's License DOUBLDE982PD Expires 1C0/4/2008 5761
OWNER, KEITH L BROSSARD PHONE: 360-344-4110
if different: DAWN A BROSSARD
200 GRIFFITH POINT RD
NORDLAND WA 983589624
PROJECT DESCRIPTION: A/G 250 GAL PROP TANK,WI GENERATOR. NO MLA REQ'D
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 6/13/2008.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:'TtF--� (—Ives _--2-0-v7
FinalApproval' C129 -{JJ
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
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, s° cow JEFFER N COUNTY `I
' 'F DEPARTMENT OF COMMUNITY DEVELOPM1 �� (���,
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, 621 Sheridan Street • Port Townsend Washington 98368
360/379-4450 • 360/379-4451 Fax
p www.co.jefferson.wa.us/commdevelopment ,�.
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11��Master Permit Application MLA: . a _I"Yl( . JProject Description(include separate sheets as necessary): /" eeRA. F' ;�� i It Tank ,ks fa J/
Tax Parc r: (i /l/0 C&o ' I Property
Number: 7 Size: (acres/square feet)
Site Address and/or Directions to Property:-c�s- 6'R t�t S WO i n� Re -x�C, /c , 4Property OwnereSs)of Record: ice ; �iba/.)i\ P R.oSSa Re
Telephone: 3(o r0"• el Q"'1Ji Fax: email:
Mailing Address: aOb 6-R i}11S�Poi►'t R.a 1 $oIkal ►A I W 0. gg,--3,SApplicant/Agent(if different from owner): !JOI 1`6le D \e e- ►ca )1 - it e.. leTelephone: 3 to D-- 38 5 --I 13 D Fax: 3101 3 g5-S 7h 1 email: v i c�si e 10 d (.tbci
ete�-S-i..c . e om.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**
NI Propane ❑ Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Perrnit Revisions**
❑Stomiwater 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 ❑Tree Vegetaion Request
*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: JI ESIGNATION OF AGENTi
I hereby designate �� l� �� to act as my agent in matters relating to this application for permit(s).OWNER SIGNATURE r Date: e,G / — eD, '
By signing this application form,the owner/agent attests that the inform Lion 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.
Date:
Signature: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 t Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf . es on ' ilit f to and complying with t A. The Applicant has read this discl�aiimerandrsign datesw.
Date: CC��
Signature:
(::\Documents and Settings\carat\Local Settings\'Temporary Interne Files\OI.K86\Master Permit Application 12-19-2006.doc
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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:
( ) ( )
MAILING ADDRESS: EMAIL: Y
CONTRACTORS LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New iii Wood Existing: Sewer
Addition ri Steel Proposed: Bank Community System
Alteration/Remodel ❑ Concrete Total: Height: Individual System
Repair Masonry SEP Permit#
Demolition L7 Other: Bedrooms: Water Supply:
Existing: Setback: Private well 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:
❑Underground Tank MAbove ground Tank Size of Propane Tank: G25O 6-&1.) ,h
0 Heat Stove OCook Stove ❑Woodstove 0 Fireplace Insert ❑Hot Water Tank ❑Pellet Stove L�,Other -ene.j{-oiZ
Is this appliance being installed in a Manufactured/Mobile Home? Yes /t��
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:
2n0 Floor Heated Consistency Review:
Other Heated Base fee: tT
Mezzanine Additional Section: r�
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL 155
5 c2
Decks 911/Rd Approach fee:
Other TOTAL: $ L 5 ��
Receipt Number: 1 I aaaq
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date:
.Fair market value of all labor and materials foundation to finish
Initials: /-
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