HomeMy WebLinkAboutBLD2011-00156r •
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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 #: BLD11-00156 _ , i Received Date 6/20/2011
SITE ADDRESS: 2481 ANDERSON LAKE RD#121- Issue Date 6/20/2011
CHIMACUM, 98325
APPLICANT: EVERGREEN COHO ESCAP RETREAT PHONE:
2481 ANDERSON LAKE RD
CHIMACUM WA 983259795
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 9/7/2012
OWNER, EVERGREEN COHO ESCAP RETREAT PHONE:
if different: 2481 ANDERSON LAKE RD
CHIMACUM WA 983259795
PROJECT DESCRIPTION: A/G 120 GAL PROP TANK
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 6/20/2012.
REQUIRED INSPECTIONS:
ankLine/Applianc l/
FinalApproval:3 h-27 -11
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
•ILDING PERMIT APPLICATA" BLD11-00156
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00156 Received Date: 6/20/2011
SITE ADDRESS: 2481 ANDERSON LAKE RD#1'' Z-
CHIMACUM, 98325
OWNER: EVERGREEN COHO ESCAP RETREAT PHONE:
2481 ANDERSON LAKE RD
CHIMACUM WA 983259795
EVERGREEN COHO ESCAPEE RESORT
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901101039 Section: 10 Township: 29 N Range: 01 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: EVELYN HONSTEEN PHONE: 360-344-4047
2481 ANDERSON LAKE RD
#221
PROJECT DESCRIPTIOI' A/G 120 GAL PROP TANK
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:
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 By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $142.00 LYK 06/20/11 123606
Total: $142.00
ON c III
od, JEFFERSON COUNTY
4� ' �+�j DEPARTMENT OF COMMUNITY DEVELOPMENT
'' ` "� 621 Sheridan Street O.
Port Townsend •Washington 98368
�� 360/379-4450 • 360/379-4451 Fax
44. www.co.jefferson.wa.us/commdevelopment
Cs
(Master Permit Application MLA: fO if,l1 ) l'
Project Description(include separate sheets as necessary):
=NDdl3"T-K. -IkL -P fe-u-PPr1-te Teo K.,
Tax Parcel Number: IC a-----7)9 Property Size: (acres/square feet)
Site Address and/or Directions to Property:
24 g t I'4}--14 DE as 1. Pr1=C- R O'2 Z. 1 C-1--A.TmAP r`c vJ P (1-S32-5--
Property Owner(s)of Record:
Telephone: Fax: email:
Mailing Address: 7-LISt 19-NDi✓2sj6T) 1--f'rK-Er✓Q Ct-t7,y-ni c.A_,t.r L -t q g3zS
pplicant/Agent(if different from owner): 6.--u e Ly N ►Ir o STEM -4
elephone: Fax: email:
Mailing Address: Z}g\. Pr Tt fl EV.5o14 L+QrJLE -f - Z Z j Cv1 c u,t,r\, l JJ H" ct 33-2_
S,---
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
❑Building 0 Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
❑Single Family ❑Garage Attached/Detached 0 Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .0 Modular - - 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essential Public Facilities)**
❑ Change of Use ❑Boundary Line Adjustment
❑ Address 0 Roa roach 0 Short Plat**
Home Business 0 Cott r— V �L�- :' Site Plan**
'Propane II. '
O LS '!r. at**
❑Sign 1 _ I Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency AIX IS ❑ 1 11 cation/Alteration**
❑ Stormwater Management ; ;i mild ❑ ,, •j-1 ne Master Program Exemption/Permit Revisions"""
❑Site Plan Approval Advance DeteirSnirjation(SF'P Ali)" 2I11 ❑4. - ne Management Substantial Development**
❑Temporary Use -1 L, ❑ :. e ine Management Variance
❑Wireless Telecommunication* F ■ • p ehensive Plan/UDC/Land Use District Map Amendment
❑ Forest Practices Act/Release of pix-Y �i COUNTY 0 Jeffer on County Shoreline Master Program Amendment
*May require a Pre-Application on NITY DEV FIOPM_ ee egetation 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).
it/OWNER SIGNATURE Date: Co I 1 -1 ( 1
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. 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 wants prior notice.
/Signature: Date: 6 ( (-7 ( ( 1
The action or a ions Applicant will undertake as a result suit 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- ble responsibil r adheri g to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
. Signature Date: w//7///
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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2011
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DEVELOPMENT
NAME ,ADDRESS &PHONE I NUMBER OF PERSON PREPARING DRAWING .
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