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Home My WebLink AboutBLD2011-00306 i i 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 #: BLD11-00306 Received Date 11/3/2011 SITE ADDRESS: 650 MONTGOMERY LN Issue Date 11/3/2011 PORT LUDLOW, 98365 APPLICANT: DAVID J MC LEOD PHONE 360-437-9276 650 MONTGOMERY LN PORT LUDLOW WA 98365-9618 55 SUBDIVISION: PORT LUDLOW NO 1 Block: Lot: PARCEL NUMBER: 990400255 Section: 9 Township: 28N Range: 01E CONTRACTOR: OWNER/BUILDER PHONE OWNER, DAVID J MC LEOD PHONE: 360-437-9276 if different: 650 MONTGOMERY LN PORT LUDLOW WA 98365-9618 PROJECT DESCRIPTION: REPLACE HOT WATER HEATER 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 11/3/2012. REQUIRED INSPECTIONS: Tank/Line/Appliance: FinalA al: 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 IILDING PERMIT APPLICA BLD11-00306 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD11-00306 Received Date: 11/3/2011 SITE ADDRESS: 650 MONTGOMERY LN PORT LUDLOW, 98365 OWNER: DAVID J MC LEOD PHONE: 360-437-9276 650 MONTGOMERY LN PORT LUDLOW WA 98365-9618 PORT LUDLOW NO 1 SUBDIVISION: Block: Lot: 55 PARCEL NUMBER: 990400255 Section: 9 Township: 28 N Range: 01 E CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE PROJECT DESCRIPTIOr REPLACE HOT WATER HEATER 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: GARAGE: SHORELINE: CONST TYPE: 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 Permit $54.00 LYK 11/03/11 128300 Plan Check $35.10 LYK 11/03/11 128300 State Building Code $4.50 LYK 11/03/11 128300 Total: $93.60 • AJ 1\ G 6- I, l l I ' Nnv - 3 JEFFERSON COUNTY ..__ C'1PT OF COI4PMi! T.N ITY UFUFIOPMENT ��, ON cod, JEFFERSON•UNTY ID . • ' DEPARTMENT OF COMMUNITY DEVELOPMENT I ` ''4 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax HIN kqs 0.o www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: MO MLA Project Description(include sep ate sheets as necssary): C-/E./et / peY r c %.c e,-----c--_,41/ Tax Parcel Number: q vl O O° Property Size: (acres/square feet) Site %/Address and/or Directions to Property: n L n I tr_� / L-7T O? f Ck k. Eq. V /('!�A-1-C3 P r,e vVc:)-_,/ k3/1 r`n -f0 itidn13F.'h c,y r-rp�,;(--- Property Owner(s)of Record: ,tilt.(r- 'Y ' i I ` Epk Telephone0.6 0) W.7- j 2 7 ( Fax: email: 9 L.,', -' c r>'''1 c,.c c/Q.ma/, -C /- Mailing Address: E•S o /le n6cs ,,,-,•.r7 /c n (_ gr - ('.,,,,)(0;A1 f (.UT ✓c,7,9 6 c- '�/' Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: at kind of Permit? (Check each box that applies 0 Lot or Road Segregation ullding 0 Critical Areas Stewardship Plan Demolition Permit 0 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(EssentialPublic-F-asilitfes ❑ Change of Use 0 Boundary Line Adjustment; ((_'� [ V ❑ Address 0 Road Approach_ 0 Short Plat .___ U ❑ Home Business ❑Cottage Industry 0 Binding Site Plan** 1 ❑ Propane 0 Long Plat** ❑ Sign 0 Planned Rural Residential Development(PRRD)/Afr�e p ents** ❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration** _,i ' d ❑ Stormwater Management 0 Shoreline Master Program Exempt '-rmi+-Ravi ions . ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management'Substantial D 1 4`frtent** ❑Temporary Use 0 Shoreline Management Variance ' ''''':'._'------- 0 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 Ptedau identify-any other kcal,state or federal permitb required for this pruposdl, 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 it mployees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of ent ,al I be assumed unless the applicant informs the County in writing at the time of the application that he or she wan nor notice. _ Signature: /? Date: rXffi G) !' The action or actions Applicant will dertake 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-transferable r sibility for • to a omplying w' he . The Applicant has read this disclaim ran igns and dates it below. dse.ignature: --' Date: G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc i • BUILDER STATEMENT The signer of this statement does hereby certify that they ar wners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming tha)responsi .• of the Generalj4or the proposed project. /� O/ �Signature: ^ �/ Date: ��/ rr \\ PHc:NE: FAx: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: ( ) ( ) 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 D Wood Existing: ❑ Sewer n ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System _ SEP Permit# _ ❑ Repair ❑ Masonry Other: Bedrooms: Water Supply: L Demolition Existing: Setback: ❑ Private well ❑ Two Party Proposed: ❑ Public Type of Heat: Total: Name of System: • If this is a Commercial Project you must answer the following: Number of ADA Parking Spaces: Number of Parking Spaces: Current: Proposed: Number of occupants(includes owners,tenants,employees, etc) Current Proposed Type Occupancy: IBC T e 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 I Above ground Tank Size of Propane Tank: I Heat Stove I Cook Stove I Woodstove I Fireplace Insert lot 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 [ urrent Proposed For Office Use O B Amount Revision ld App Review: Main Floor Heated 2"d Floor Heated Consistency Review: — Other Healed base tee: nq Mezzanine Additional Section: , Heated Basement Plan Check fee: 2J • I- Unheated Basement State Surcharge fee: � `r Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: ,. Other TOTAL: $ "t , eon Receipt Number: 181(nCC) Cash/Check Number: i 2 "tSTIMATED COST(REQUIRED) Date: — -- •Fair market value of all labor and materials foundation to finish lL 5OCil Initials: S G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc