HomeMy WebLinkAboutBLD2010-00340 w •
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 #: BLD10-00340 Received Date 9/23/2010
SITE ADDRESS: 311146 HWY 101 Issue Date 9/28/2010
BRINNON, 98320
APPLICANT: DAVID R GARDNER PHONE: 360-796-3749
ANNA M GARDNER
643 SALMON ST
BRINNON WA 98320-9627 3+
SUBDIVISION: JOHNSTON SHORT PLAT#3 Block: Lot:
PARCEL NUMBER: 502213024 Section: 21 Township: 25N Range: 02W
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, DAVID R GARDNER PHONE: 360-796-3749
if different: ANNA M GARDNER
643 SALMON ST
BRINNON WA 98320-9627
PROJECT DESCRIPTION: NEW WOODSTOVE IN EXISTING SFR-SEE BLD07-572
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 9/28/2011.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: l / ( 7173
FinalApproval:
/ l/
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
BLD10-00340
IRUILDING PERMIT APPLICA�ON Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD10-00340 Received Date: 9/23/2010
SITE ADDRESS: 311146 HWY 101
BRINNON, 98320
OWNER: DAVID R GARDNER PHONE: 360-796-3749
ANNA M GARDNER
643 SALMON ST
BRINNON WA 98320-9627 JOHNSTON SHORT PLAT#3
SUBDIVISION: Block: Lot: 3+
PARCEL NUMBER: 502213024 Section: 21 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION NEW WOODSTOVE IN EXISTING SFR - SEE BLD07-572
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 2009 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 $142.00 LYK 09/23/10 120122
Total: $142.00
4.o..SON cOO JEFFERSO�COUNTY
W ' aQ; DEPARTMENT OF COMMUNITY DEVELOPMENT
`' ''' M 621 Sheridan Street• Port Townsend • Washington 98368 SEP 2 3 2010
_ 360/379-4450 • 360/379-4451 Fax
�qs p$ www.co.jefferson.wa.us/commdevelopment
DYING
Master Permit Application MLA:
Project Description(indude separate sheets as necessary):
Install New Wood Burning Stove in Residence •
Tax Parcel 502213024 Property 5.5
Number: Size: (acres/square feet)
Site Address and/or Directions to Property: 311146 HIGHWAY 101 BRINNON WA 98320
Enter at 643 Salmon Street.Right on Hwy 101(headed south)2nd left on Pooh Alley,then immediate left on Salmon Street
(dead end)go to end and up hill at 643 Salmon Street-call if any issues.Call first to make sure dogs are not out.
Property Owner(s)of Record: DAVID GARDNER ANNA M GARDNER
Telephone:360-796-3749 Fax: email: destinye@earthlink.net
Mailing Address: PO BOX 81 BRINNON WA 98320
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies
❑Building 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑Conditional Use[C(a), C(d),or C]**
0 Single Family 0 Garage Attached/Detached ❑Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* 0 Boundary Line Adjustment
❑ Change of Use 0 Short Plat'"`
❑ Address ❑Road Approach 0 Binding Site Plan**
0 Home Business 0 Cottagelndustry 0 Long Plat'"'
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Sign ❑Plat Vacation/Alteration**
❑Allowed"Yes" Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
0 Stormwater Management 0 Shoreline Management Substantial Development**
0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance
❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment
0 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 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 em loyees,representatives or agents for the sole purpose of application
review and any required later inspections. StafFs a try wi assumed unless the applicant informs the County in writing at the
time of the application that he or she wants p•
Signature: �� c r�/�s,�g Date: 9.20.2010
The action or actions Applicant wi ndertake 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 compli fferson County develo ment code.The Applicant acknowledges that he,she or it holds individual
and non-transfers Eresponsibi for adherin d-coming " the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: l 'A-,,,,r,/ Date: 9.20.2010
C:\llocuments and Settings\caral\Local Settings\'Temporary Internet Files\OLK86\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 on actor for the proposed project.
Signature: • �/�� Date: 9.20.2010
GENERAL CONTRACTOR OR ANUFACTURED HOME INSTALLER: PHONE: FAx:
Rich's for the home-Installer,licensed and bonded. ( 425)742-7283 ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: N/A PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
IA New Wood Existing: a Sewer
ri Addition ❑ Steel Proposed: Bank LI Community System
it Alteration/Remodel ❑ Concrete Total: Height: Individual System
11 Repair ❑ Masonry SEP Permit#
11 Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: Li Private well Two Party
Type of Heat: Proposed: [I 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 Cj Above ground Tank Size of Propane Tank:
❑Heat Stove 0 Cook Stove Woodstove 0 Fireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes / N/l5
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"°Floor Heated Consistency Review:
Other Heated Base fee: /
Y2-Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL A./
Decks 911/Rd Approach fee:
Other TOTAL: $ /�if�—
Receipt Number: / /0/22
Cash/Check Number: /03
ESTIMATED COST(REQUIRED) Date: /7 �_
.Fair market value of all labor and materials foundation to finish /�}
Initials:
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