HomeMy WebLinkAboutBLD2007-00576 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 #: BLD07-00576 Received Date 11/13/2007
SITE ADDRESS: 2481 ANDERSON LAKE RD#633 Issue Date 11/13/2007
CHIMACUM, 98325
APPLICANT: EARL F JONES JR PHONE: (360) 379-1378
2481 ANDERSON LAKE RD#633
CHIMACUM WA 98325
SUBDIVISION: EVERGREEN COHO ESCAPEE RESORT Block: Lot:
PARCEL NUMBER: 901101039 Section: 10 Township: 29N Range: 01W
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, EVERGREEN COHO ESCAP RETREAT PHONE:
if different: 2481 ANDERSON LAKE RD
CHIMACUM WA 98325-9795
PROJECT DESCRIPTION: INSTALL A/G 120 GAL PROPANE TANK AND LINES
Directions
To Site:
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 11/13/2008.
REQUIRED INSPECTIONS:
ank Line/Appliance: 0. 1,(9
FinalApproval: I 2---2C -1 t _A
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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DEPARTMENT OF COMMUNITY DEVELOPMENT
`".) �� 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax 0 U 1 3 2007
,ys 0 www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: `�' F co
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Project Description (include separate sheets as necessary): r
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Tax Parcel Property
Number: y0/ /0/ 037 Size: (acres/square feet)
Site Address and/or Directions to Property:
£{ r A Jc 4 h , Al 633 C ,,,� ,,� c Pik ci 3 2 S
Property Owner(s)of Record: `��oC#2 lict=rti' conk) ,tom
Telephone: See ?2 E S 3 Fax: email. cf_CC� •f' Ci' -f •Ca,,,N
Mailing Address: .2 - ' .N e,4, 4 C4 CAU y R 32 s 633
Applicant/Agent(if different from owner): tC %
Telephone: (34 G) 3 7"1 /3 72 FFa��x: email:
Mailing Address: 24ril A .*c' ( ie(3.3
What kind of Permit? (Check each box that applies
(Building 0 Variance (Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home 0 Modular ❑ Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
❑ Change of Use 0 Short Plat**
❑ Address ❑ Road Approach 0 Binding Site Plan**
❑ Home Business ❑ Cottagelndustry 0 Long Plat**
l2 Propane 0 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
0 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 .� /r i 1 s`'f 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 ins ctions. St s access and right of entry will be assumed unless the applicant informs the County in writing at the
time of the ap liccattiionn at hh o she wants for notice. , �_1 �/
Signature: Date: 13 AA) /
The action or actions Applica t 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-tran b res nsi lity for adh ring to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date: / 3 AJ&.J r&u7
i
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:
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 ❑ 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 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 antltQr ADDIiaLl�ce Installation permit,mark all items below that apply:
i Under round Tank Above ground Ta Size of Propane Tank:
i eat Stove Cook Stove I Woo stove Fireplace Insert Hot Water Tank Pellet Stove Other
Is t i - nce 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"tl Floor Heated Consistency Review:
Other Heated Base feed {rW 1b Oc
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Iaa.o0
Decks 911/Rd Approach fee:
Other TOTAL: $ L Da 0 4
Receipt Number: 9,5 U &L I
Cash/Check Number: 504
ESTIMATED COST(REQUIRED) Date: (3 l U7
•Fair market value of all labor and materials foundation to finish
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc