HomeMy WebLinkAboutBLD2012-00012 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 #: BLD12-00012 Received Date 1/9/2012
SITE ADDRESS: 141 MONTGOMERY LN Issue Date 1/10/2012
PORT LUDLOW, 98365
APPLICANT: STEPHANIE A TOMPSON PHONE: 360-215-4124
SCOTT A TOMPSON
141 MONTGOMERY LN
PORT LUDLOW WA 98365-9602 1
SUBDIVISION: PORT LUDLOW NO.2 Block: Lot:
PARCEL NUMBER: 990600157 Section: 9 Township: 28N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/ 085 5875
OWNER, STEPHANIE A TOMPSON PHONE: 360-215-4124
if different: SCOTT A TOMPSON
141 MONTGOMERY LN
PORT LUDLOW WA 98365-9602
PROJECT DESCRIPTION: A/G 120 GAL PROP TANK, LINES & COOK 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 1/10/2013.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: /4\4' 4 / /,n e f / 4‘,0/$0_ 12SJf 1. .2_ 7, 7e. /7y
FinalApproval: 4— I .4-1.i--
r
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
WILDING PERMIT APPLICA•N BLD12-00012
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00012 Received Date: 1/9/2012
SITE ADDRESS: 141 MONTGOMERY LN
PORT LUDLOW, 98365
OWNER: STEPHANIE A TOMPSON PHONE: 360-215-4124
SCOTT A TOMPSON
141 MONTGOMERY LN
PORT LUDLOW WA 98365-9602 PORT LUDLOW NO.2
SUBDIVISION: Block: Lot: 1
PARCEL NUMBER: 990600157 Section: 9 Township: 28 N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2012
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTION A/G 120 GAL PROP TANK, LINES & COOK 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:
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 $222.00 LYK 01/09/12 131363
Total: $222.00
SITE VISIT REPORT
•
(PLOT PLAN)
JOB C.4t. 7 - GG►S�?� DATE: ��2- ' / 2�t� CONTACT:
ADDRESS l t4 f74'7�fL:�a E'er/ P ONE #: 316-e'_'2d,J - V/ZK'
DIRECTIONS %�� /t:.0,/67442 FAX #:
Email _
PLANNER: 1V1.
Include all street names adjacent to property,property lines,tank, appliance&piping locations, distances of tank to property lines and
buildings, septic, wells, wetland areas,distance to water bodies.
ID &:
?i(RDE:9
1�111 �
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JEFFERSON COUNTY
DEPT.OF COnItAIfY OFVFI O!'MFNT'
j •
� �� JEFFERSON COUNTY •
\•� DEPARTMENT OF COMMUNITY DEVELOPMENT
a 621 Sheridan Street• Port Townsend •Washington 98368
e
' ,. 360/379.4450 • 360/379-4461 Fax
www.co.Jefferson•wa,us/commdevelopment
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Master Permit Application MLA: U0 MCA eEig '6
P5ject•Description(include separate sheets as necessary): -
W tij 7`ilt9 /P4-e72 -- / .(tee_
' ,-
Tax Parcel Number: G r/
q 010(0( LS-1 Property Size:
Site Address and/or Directions to Property:
(acres/square feet)
4 .LII_�-ab Lj.., ,K ( . We
Property Owner(s)of Record; I i TO th S 0
Telephone:Y4=.6--2(S " `f-(--c.( Fax: v
Mailing Address: I. ( /11 OYIT 6 DtN L 1— email:
Appifcant/Agent(if different from owner): _ pA__a->e.A,--e_____--
Telephone: 9'&5 57 7 Fax: 38 5 875;
Mailing Address: /C 8,,53 ,�f-/o v ,0P. Pi email: �S d�h-� y� �
y . f��coc�� �A
What kind of Permit?(Check each-box that applies- 0 Lot or Road Segregation
0Building 0 Critical Areas Stewardship Plan
❑ Demolition Permit 0 Varian a(Minor, Major or Reasonable Economic_Use
❑ Single Family o Garage Attached/Detached 0 Conditional Use[C(a) C(d) or _0 Manufactured Home -GI Modular - 0 Discretionary"p"orUnnam,e UseiClatsi�catl&
❑ Commercial* 0 Special Use(Essential'Publii;Facili ies)**-
❑ Change of Use 0 Boundary Line Adjustment
Address 0 Road Approach 0 Short Plat**
❑ Home Business ❑Cottage Industry 0 Binding Site Plan**
t)Ippropane
0 0 Long-Plat'* JJ
❑ Signilowed"Yes"Use Consistency Analysis • 0 Planned Rural Reeidenttai-Dc tlopme� end ents** .
❑Stormwater Management 0 Plat Vacation/Altetation** n .
❑Site Plan Approval Advance Determination(SPAAD) 0 Shoreline Master Program-tzernption/Permit'• •
0 Temporary Use - n 1 Shoreline Management Substantial Development**
UseTelecommunication* ❑Shoreline Management Variance
❑ Forest Practices Act/Re of Six-Year Moratorium 0 Comprghensive Plan/UDC/Land Use District Map Amendment
❑JeffersonCounty Shoreline Master Program Amendment
*May require a Pre—AppOcatlon Conference 0 TreeTree Vegetation:Request
**Requires;a Pre-Application Conference
Please identify any other local,state or federal permits required;for this proposal, if known:
I ereby designate DESIGNATION OF AGENT
to act as myagent in matters relating to this application for permit(s).
',0 o WNER SIGNATURE ........ �j 40—' •
Date: lZ Z.-•,
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 requir 'later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the.
' time of the appli--"•n t •r, or s - any prior notice,
f ••nature: ���
1 Date: zz3 4
The action or actions •pplicant.will undertake as a result of the issuance of this permit may negatively Impact upon one or mote 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 yo re in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfer ere 'bill r adhering to and complying,with the ESA. The Applicant has read this disci imer and sig s and dates it below.
Signature:
t� Date: Z f
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• •
BUILDER STATEMENT
The signer of this statement does I ereby 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:,
1
GENERAL CONTRACTOR ER: PHONE: FAX:
_ 51.La�. s in e rP 2_A- I° (?6o ) 3 FS- _r 7 /7 ( 3 Gc) 3 S- P 7-5-
MAILING ADDRESS: 'C7 5 3 01, 2 �t pi- P. (-( EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: 5 to S c/f1 7 Q NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New 0 Wood Existing: 0 Sewer
❑ Addition 0 Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel 0 Concrete Total: Height: ❑ Individual System
O Repair 0 Masonry SEP Permit#
O Demolition 0 Other: Bedrooms: Water Supply:
Existing: Setback: p Private well [3 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: C rrent: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes wners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food'Service? Yes / No
4---if this is,a Propane Tank and/ r Appliance Installation permit,mark all items below that apply: �,,_p
1 Underground T Above ground Tan j /c9, Size of Propane Tank: / z0 �o rig r"�" I
1 Heat Stove (Cook St 1 Fireplace Insert 1 Hot Water Tank 1:Pellet Stove 1 Other . e c rl-{
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. y
•,p t �1 xh +ri a i p°.3'' F t ',,; ya` 3 NAt vi, q i S s ...4. r,y f' .ff ,,,.•
4z�� 5
S•uare Foote'e Current Pro•osed .g.`�,c ik . .,:F, i i,4 ;t u•• :116! .a liY -If c 14.u.,4/ 1,ii: - t. .; s A.z
Main Floor Heated s . s.�e4� �' EH BId App Review:
t`,$ lY,
2"d Floor Heated sa r Wyk` Consistency Review:
t'' „-M 1
Other Heated $ `,�rr,11' T; Base,fee:
t4u 2 I'
- n4"* " Additional Section:
Mezzanine �f� A• x'�w�'a`
0 � s^ ;' + ,
Heated Basement ';� ;44a ` Plan Check fee:
Unheated Basement $ •# {1. State Surcharge fee:
' Other Unheated `of, Pot Water Review fee:
s" 'At ,'-- I,
Garage/Carportl‘s-- _, •;� s% 4. SUBTOTAL
Decks xr, Iw ''"t,� ' 911/Rd Approach fee:
a ; �
Other . TOTAL: $st.., ,...,,,?,„„t,
a„),,tv,' � Receipt Number 13136
'3��.��n • Cash/Check Number:.
ESTIMATED COST(REQUIRED) Date: (_
•Fair market value of all labor and materials foundation to finish Initials:
ice._
G:\PermitCenter\###FORMS###\DRD FORMS\Current DAD Forms\Master Permit Application 5-29-08.doc