HomeMy WebLinkAboutBLD2007-00538 •
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 #: BLD07-00538 Received Date 10/11/2007
SITE ADDRESS: 830 OLYMPUS BLVD Issue Date 10/11/2007
PORT LUDLOW, 98365
APPLICANT: CLARENCE E MILLER TRUSTEE PHONE: (360) 437-2925
NANETTE S MILLER TRUSTEE
830 OLYMPUS BLVD
PORT LUDLOW WA 98365-9416 5
SUBDIVISION: BASALT BEACH Block: 1 Lot:
PARCEL NUMBER: 931500104 Section: 4 Township: 28N Range: 01E
CONTRACTOR: WESTSOUND CHIMNEY SERVICE PHONE: 360-698-4669
8322 BIG BIRD DR
SILVERDALE WA 98383
Contractor's License WESTSCS933M6 Expires 7/26/2009
OWNER, CLARENCE E MILLER TRUSTEE PHONE: (360) 437-2925
if different: NANETTE S MILLER TRUSTEE
830 OLYMPUS BLVD
PORT LUDLOW WA 98365-9416
PROJECT DESCRIPTION: INSTALL WOODSTOVE IN MODULAR HOME - NO MLA REQ'D
Directions GO TO PORT LUDLOW RESORT,GO NORTH ON OAK BAY RD TO REMAX,TUIRN RGHT ON OLYMPUS
To Site: BLVD TO 830 OLYMPUS BLVD
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 10/11/2008.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:
FinalApproval:
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
S ILDING PERMIT APPLICATA BR view Ty 5538
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00538 Received Date: 10/11/2007
SITE ADDRESS: 830 OLYMPUS BLVD
PORT LUDLOW, 98365
OWNER: CLARENCE E MILLER TRUSTEE PHONE: (360)437-2925
NANETTE S MILLER TRUSTEE
830 OLYMPUS BLVD
PORT LUDLOW WA 98365-9416 BASALT BEACH
SUBDIVISION: Block: 1 Lot: 5
PARCEL NUMBER: 931500104 Section: 4 Township: 28 N Range: 01 E
CONTRACTOR: WESTSOUND CHIMNEY SERVICE PHONE: 360-698-4669
8322 BIG BIRD DR
SILVERDALE WA 98383
Contractor's License WESTSCS933M6 Expires 7/26/2009
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP INSTALL WOODSTOVE IN MODULAR HOME - NO MLA REQ'D
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 2006 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 By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $102.00 KAS 10/11/07 S3368
Total: $102.00
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W g� DEPARTMENT OF COMMUNITY DEVELOPMENT
ti v ` 'Q 621 Sheridan Street • Port Townsend •Washington 98368
�.�... ,, 360/379-4450 • 360/379-4451 Fax OCT 1 1 2007
4..qs, 7NOHO www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLAifFEIN COUNTY BCD
Project Description (include separate sheets as necessary):
,w-t' . .4 , tiir eL i»mw Ce..k., "C'...2 1-(, -,G 'r CG(., GC-✓\_,
Tax Parcel Property
Number: 3/ Strr I G �' Size: �. �7 t, (acres/suare feet)
G,:, v. Fe l,i; oi.c,�v (.- 1e- 16-z0 k..:1 i c2:,) 0AS3 li' P-p lT c
Site Address and/or Directions to Property: f �ict, ru l��
?i z 04Y- I PO S .:VP PGgr L )PL-0 Lci, pi,..4 ' E.�
Property Owner(s)of Record: Li..Z_Ag ��/,-- Ai)/L-!
Telephone:' n Z- 7 7 4)ZS Fax: email:
Mailing Address: C OLyrV),ac.; l- r> /?Ci/,'�L-Uc)L0t.[J' L-ti'4t--
Applicant/Agent(if different from owner): C) /
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 0 Garage Attached/Detached El Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home ❑ Modular ❑ Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
❑ Change of Use ❑ Short Plat**
❑ Address 0 Road Approach ❑ Binding Site Plan**
❑ Home Business 0 Cottagelndustry 0 Long Plat**
❑ Propane ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Sign 0 Plat Vacation/Alteration**
❑Allowed "Yes" Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium 0 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:
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 is priornice.
Signature: L €t.,Ct1 . ������L2 Date: /O i //; 6.7
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�n�!complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: V�L?Q,✓ /�'�,vu�/Ja[/�i1 . Date: /6/ //• C)7
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.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:
141 i- ZC,%1Jc7 C-7-4 /.11i\y am—"�—"��:/[ �` (?mac` ) q'
MAILING ADDRESS: 6.•j6 4 vK �-7-L i EMAIL: �� '> I
CONTRACTORS LICEN E i t ✓ ��
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 ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ 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 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 I Above ound Tank Size of Propane Tank:
Heat Stove i Cook Stove (Woodstove I Fireplace Insert i Hot Water Tank Pellet Stove i Other
Is this appliance being installedin 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: ,��-L
LOovQ. I Da.00
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
►DaDo
Decks 911/Rd Approach fee:
Other TOTAL: $ /OD.op
Receipt Number: "l3
Cash/Check Number: &J G
ESTIMATED COST(REQUIRED) Date: 1 r /r )O�
•Fair market value of all labor and materials foundation to finish /
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
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