HomeMy WebLinkAboutBLD2011-00323 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 #: BLD11-00323 Received Date 12/5/2011
SITE ADDRESS: 1121 SHINE RD Issue Date 12/5/2011
PORT LUDLOW, 98365
APPLICANT: JUDITH V JOHNSON PHONE: 360-643-3167
1234 SHINE RD
PORT LUDLOW WA 98365-9511
TX 5
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 821343014 Section: 34 Township: 28N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
OWNER, JUDITH V JOHNSON PHONE: 360-643-3167
if different: 1234 SHINE RD
PORT LUDLOW WA 98365-9511
PROJECT DESCRIPTION: A/G 250 GAL PROPANE TANK, LINE & HEAT STOVE
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 12/5/2012.
REQUIRED INSPECTIONS:
Tank/Line/Appliance:74/4. //v'r= 6pT /-„2(f, -/ Z S/`a .1 r3 /
/ Igt
FinalApproval: " 3 /
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_Perm it_Propane.rpt 10/29/19
tILDING PERMIT APPLICA1IN B
Review 0323
Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD11-00323 Received Date: 12/5/2011
SITE ADDRESS: 1121 SHINE RD
PORT LUDLOW, 98365
OWNER: JUDITH V JOHNSON PHONE: 360-643-3167
1234 SHINE RD
PORT LUDLOW WA 98365-9511
SUBDIVISION: Block: Lot: TX 5
PARCEL NUMBER: 821343014 Section: 34 Township: 28 N Range: 01 E
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: CHRISTIAN JOHNSON PHONE: 360-643-3168
1121 SHINE RD
PORT LUDLOW WA 98365
PROJECT DESCRIPTIOI' A/G 250 GAL PROPANE TANK, LINE & HEAT STOVE
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 $213.00 LYK 12/05/11 128368
Total: $213.00
rik6
gON C JEFFERSON�UNTY •
�, DEPARTMENT OF COMMUNITY DEVELOPMENT
t' \ 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�rgs� ��p www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: Vv 0 c Y1L - ¶t
Project Description(include separate sheets as necessary):
1 Yi(ft�V i f r✓lAvv, Ton(` L o r�Utr f'I�fi LA/O fs i rQ Olt & 'i 9" C e'
Tax Parcel Number: (7)/ , `f 3 ®/ Property Size: , '/ ' r (acres/square feet)
Site Address and/or Directions to Property: ( ( Zll >k(„toot../
e l
Property Owner(s)of Record: -174 t' r ‘/, in,n<on
Telephoner;i 60) L4-` '-31676- Fax: email: -T &-s i )n 1 iV0.cor i
Mailing Address: /2-3 '+ S'" iY ' r 4mc-- t r�Ior/., L,/A
Applicant/Agent(if different from owner): (� r";S ri`a n 1 i'1/LCor1
Telephone: (T&O &)-" X 1( ' Fax: email:.A.KA-.)0tinsonI trw.J.Gom
Mailing Address: ii Z ) SI,kL' t.,/A
What kind of Permit?(Check each box that applies
❑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]**
❑ Manufactured Home 0 Modular 0 Discretionary"D"or Unnamed Use Classification
❑ Commercial* 0 Special Use(Essentlaa Ms)
❑ Change of Use 0 Boundary Line Acljus t LE
❑ Address 0 Road Approach 0 Short Plat** r
0 Home Business 0 Cottage Industry 0 Binding Site Plan**
-) ..Propane 0 Long Plat**
❑ Sign 0 Planned Rural Residerii�l Development(P endments**
❑Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration*" I
❑Stormwater Management 0 Shoreline Master ProgramFvPmption/Pemh ev sions**
❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Subit@i16t1 D'evelopmenti*
❑Temporary Use ❑ Shoreline Management VarianckDEVELDPMENT
❑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:
f I DESIGNATION OF AGENT
I hereby designate 1/t '�� JUI4r)�(J►'l to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE L�� Date: /}//
By signing this application form,the owner/age '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 t t he or she wants prior notice. k) / / /
Signature: Date:
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 Je erson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transferable responsibility for adheri g and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: i/I Date: :l/ (
U:\PemvtCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.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 the General Contractor for the proposed project.
Signature: 1-1%/�i!-h4f )/t-7 l-t% Date: /fi// / //
GENERAL CONTRACTOR OR MANUFACTURED 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:
J New i i Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit#
❑ Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: I i 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:
Und round Tank(i Above ground Tank Size of Propane Tank: S L' c a-(cril 'S/?
eat Stove I Cook Stove i Woodstove T Fireplace Insert i Hot Water Tank I Pellet Stove I Other
s is appliance being installed in a Manufactured/Mobile Home? Yes /
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 ,,�/oUO6� EH Bld App Review:
2nd Floor Heated Consistency Review:
Other Heated Base fee: `a'
Mezzanine Additional Section: 'J
Heated Basement Plan Check fee:
(
Unheated Basement Sfatl r-;llgefi V
Other Unheated • ; .Pot Water Review fee:
Garage/Carport SUBTOTAL I J
•
Decks 911/Rd ApprOaRffemTY
nFPT.OF COMM'! "TY CPMFq _
Other TOTAL: $
Receipt Number: ?cg
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date: _�-
.Fair market value of all labor and materials foundation to finish 1 2
—I L L
Initials:
G:\PemutCenter\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
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