HomeMy WebLinkAboutBLD2009-00251 • •
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 #: BLD09-00251 Received Date 8/3/2009
SITE ADDRESS: 140 N STROMBERG AVE Issue Date 8/3/2009
PORT TOWNSEND, 98368
APPLICANT: TERRY F COPELAND PHONE: 360-385-5132
CHRISTINE RUMMER
21810 76TH AVE W STE 201
EDMONDS WA 98026-7917 25-29
SUBDIVISION: IRONDALE Block: 151 Lot:
PARCEL NUMBER: 962115126 Section: 35 Township: 30N Range: 01W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, TERRY F COPELAND PHONE: 360-385-5132
if different: CHRISTINE RUMMER
21810 76TH AVE W STE 201
EDMONDS WA 98026-7917
PROJECT DESCRIPTION: INSTALL NEW HEAT PUMP
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 8/3/2010.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:
FinalApproval: k-Z`f -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
I:\F_BLD_Permit_Propane.rpt 10/29/19
Ii ILDING PERMIT APPLICATI BLD09-00251
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD09-00251 Received Date: 8/3/2009
SITE ADDRESS: 140 N STROMBERG AVE
PORT TOWNSEND, 98368
OWNER: TERRY F COPELAND PHONE: 360-385-5132
CHRISTINE RUMMER
21810 76TH AVE W STE 201
EDMONDSWA 98026-7917 IRONDALE
SUBDIVISION: Block: 151 Lot: 25-29
PARCEL NUMBER: 962115126 Section: 35 Township: 30 N Range: 01 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION INSTALL NEW HEAT PUMP
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION ADD'L: HEAT TYPE:
CODE EDITION: 2006 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE SHORELINE:
GARAGE: SETBACK:
CONST TYPE: 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
Permit $142.00 LYK 08/03/09 110667
Total: $142.00
0ON •', JEFFERSO UNTY
bc; . kiii. ,4 OEPARTMENTT COMMUNITY DEVELOPMENT
`'� 621 Sheridan Street • Port Townsend •Washington 98368
360/379-44M• 360/379-4451 Fax
�q`S'$rNG.',spy www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: KlO l' -1( A 19.,e0 1')
Project Description(include separate sheets as necessary):
/'NSTY4Lc.. i-1( .F{; p rr'f
Tax Parcel Number: q b z I f '' 2 6, Property Size: t z/ik 5 cc `t' (acre quare feet
Site Address and/or Directions to Property:
l 4'G N S 7"/=2U/'7 c3L /4. (3
Property Owner(s)of Record: Tc-122y r, C-tin( s c_o Pi i-A"/17
Telephone: i,,, - 3-�_ s'r- - Fax:
email: I. u v J C 0 cClYr,c_•=c s,a.-
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Mailing Address: --7 ?.z / a z- f's- s ---
Applicant/Agent(if different from owner): \..irk-s h: -\-erg ' 'e r•y; ce r v,c_&s C r.,.-
Telephone: ,9'90--35�— I-/66- Fax: 2 G "-3-7 -C°("°° email: c�a.sh,,,J fr. , t2r,�f'9 . (.-car,
Mailing Address: L f-3<! ill 5.,--A dot(e, c� A... IS e0 }�-l L - A- 9 v l 947
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What kind of Permit?(Check each box that applies
l'Building rICA r Pamv:' ❑Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
❑Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a),C(d),or CJ*"'
❑ Manufactured Home 0 Modular 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)**
❑ Change of Use 0 Boundary Line Adjustment
❑ Address 0 Road Approach 0 Short Plat**
❑ Home Business 0 Cottage Industry 0 Binding Site Plan**
Propane ❑Long Plat**
❑Sign 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration**
❑Stormwater Management 0 Shoreline Master Program Exemption/Permit Revisions**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
❑Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Ad/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment
*May require a Pre—Application Conference 0 Tree Vegetation Request
**Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known:
L£I 7 fGAL r62, ,
DESIGNATION OF AGENT
I hereby designate i W 7"-- E.,o"ry J Serr r s to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE %S'4LL.. � �; � r
„ ,
' -6 L , Date: -,
IZ.k.17/ 0 9
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 its 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 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 wen?prior notice.
Signature: -�; 1 lY�._C �A . Date: /1 / q
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-trintiferiable responsibility for adhering to and complyi} with the ESA. The ApplicantJ has read this discla' er aj'd sign and dates it below.
Signature: ,�y Si__ _I '`-LQ�yv�,.r�(� tt �, _Li r _'A Date: li'"/ / 0 r
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc [[l !«
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BUILDER STATEMENT •
The signer of thi._l sf tsment does hereb -rtify th. t -y are th- • ners of the parcel referenced herein,that they are not licensed contractors and that
they will be assunin th responsibility.f , 0 : a Contract. i r the proposed pro'
+Signature: I • 1 Date: 3/6(..,
GENERAL CONTRACTOR OR MA FACTUR:D 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#
II 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 Projectyouu 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 U• nderground Tank i Above ground Tank Size of Propane Tank:
i H• eat Stove i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other
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:
2n°Floor Heated Consistency Review:
Other Heated Base fee: 4, . - _
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: $ I 1-4
Receipt Number:
Cash/Check Number:
— ESTIMA ' D COST(REQUIRED) Date:
•Fair ma value of all labor and materials foundation to finish
r4j 00/) Initials:
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