HomeMy WebLinkAboutBLD2010-00374I
• S
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 #: BLD10-00374 Received Date 11/1/2010
SITE ADDRESS: 151 POINT VIEW AVE Issue Date 11/1/2010
BRINNON, 98320
APPLICANT: WAYNE SCHLAEFLI PHONE: 360-796-4847
PO BOX 130
BRINNON WA 98320
40+
SUBDIVISION: OLYMPIC CANAL ADDITION 3 Block: 7 Lot:
PARCEL NUMBER: 980700724 Section: 21 Township: 25N Range: 02W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2012
OWNER, WAYNE SCHLAEFLI PHONE: 360-796-4847
if different: PO BOX 130
BRINNON WA 98320
PROJECT DESCRIPTION: A/G 250 GAL PROP TANK REPLACEMENT-SAME SIZE &
Directions LOCATION
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 11/1/2011.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:
r
FinalApproval: /t- \1-23— (V
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
B RType 4.UILDING PERMIT APPLICA Review
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD10-00374 Received Date: 11/1/2010
SITE ADDRESS: 151 POINT VIEW AVE
BRINNON, 98320
OWNER: WAYNE SCHLAEFLI PHONE: 360-796-4847
PO BOX 130
BRINNON WA 98320
OLYMPIC CANAL ADDITION 3
SUBDIVISION: Block: 7 Lot: 40+
PARCEL NUMBER: 980700724 Section: 21 Township: 25 N Range: 02 W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2012
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOP A/G 250 GAL PROP TANK REPLACEMENT - SAME SIZE & LOCATION
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION ADD'L: HEAT TYPE:
CODE EDITION: 2009 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: Prop:
Total: Total:
Routing Date:
Type Amount Paid Bv: Date: Receipt: Approved/Date
Propane Tanks/Stoves $71.00 LYK 11/01/10 120239
Total: $71.00
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I Surface water(ponds,creeks,etc)J ►MIDI/Th DERl 3" aP North Arrow
d Buildings(residence,sheds,garages,etc)
PLOT PLAN-date prepared
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40oN c0 JEFFERSOPOUNTY
W ' \� DEPARTMENT OF COMMUNITY DEVELOPMENT
'' 4\ 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
4� �� www.co.jefferson.wa.us/commdevelopment
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Master Permit Application MLA: N0 rLb,
Project Description(include separate sleets a ne s ry):
TI‹ JJ T Sil_
Cj IL= KO A — M,e J l70 f —1 d 1J
Tax Parcel Number: 9 b 7(..DD-7 2-9 Property Size: (acres/square feet)
Site Address and/or Direction to Property:
/5/ 'f1'7 (� e w�A-�'e V) 0b7C 144 /4 7 3Z
Property Owner(s of Record: t�)�yv� _S C H LAL / L^ /
Telephone: / r Fax: email:OAY`/e c>tieNz.o R►or
Mailing Address: ,.00 .3 ✓ < < en). -cd,*
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
❑Building 0 Critical Areas Stewardship Plan
❑ Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use)
❑Single Family 0 Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]**
O Manufactured Home. . 0 Modular - 0 Discretionary"D"or Unnamed Use Classification
0 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 ❑Binding Site Pian r`-
L01'ropane ❑ Long Plat**
❑ Sign - 0 Planned Rural Residential Development(PRRD)/Amendments** '
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration*''`
❑ Stomiwater Management ❑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 Act/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:
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 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 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.tiIio���iiis.j Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the
time ofth- -y %•:tion tha he • she `s pri•,n•tice.
Signature: /�/ f Date: 1////247.
/ C---)
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 tederal 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- e respon ability r a' e'ng to nd complying with the ESA. The Applicant has read this disci err nd signs and dates it below.
3 Signa ure: ` Date: (7 7ja_(? D
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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:
o ( ) ( )
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 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:
i Underground Tank CAbove ground Tank Size of Propane Tank: 9-5.l
Heat Stove cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other %?vt'fZ
Is this appliance being installed in a Manufactured/Mobile Home? Yes / o
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 BId App Review:
2nd Floor Heated Consistency Review:
Other Heated Base fee: I I
Mezzanine Additional Section: 1
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/R I Approach fee:
Other TOTAL $ r
Receipt Number: �2 e z
Cash'Check Number:
__ _
Al / >
ESTIMATED COST(REQUIRED) Date: I � �
( �
•Fair market value of all labor and materials foundation to finish -tom'►
Initials: (__ `
_/
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