HomeMy WebLinkAboutBLD2012-00195 • •
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#: BLD12-00195 Received Date 6/25/2012
SITE ADDRESS: 295 PORTER LN Issue Date 6/25/2012
PORT TOWNSEND, 98368
APPLICANT: DEAN E ROLLINGS JR TRS PHONE: 360-379-2560
DEAN ROLLINGS JR REV TRST
2710 THOMES AVE#657
CHEYENNE WY 82001-3029 TX 46
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001063013 Section: 6 Township: 30N Range: 01W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/1602012-5875
OWNER, DEAN E ROLLINGS JR TRS PHONE: 360-379-2560
if different: DEAN ROLLINGS JR REV TRST
2710 THOMES AVE#657
CHEYENNE WY 82001-3029
PROJECT DESCRIPTION: A/G 250 GAL PROP TANK -SAME SIZE & LOCATION
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 6/25/2013.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: g bi 4 c(J ,26-' - /2 /7713
FinalApproval: I ..2_r - 7 / Z5
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
\\tidemark\data\forms\F_BLD_Perm it_Propane.rpt 6/25/2012
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ILDING PERMIT APPLICAN BLDI2-00195
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD12-00195 Received Date: 6/25/2012
SITE ADDRESS: 295 PORTER LN
PORT TOWNSEND, 98368
OWNER: DEAN E ROLLINGS JR TRS PHONE: 360-379-2560
DEAN ROLLINGS JR REV TRST
2710 THOMES AVE#657
CHEYENNE WY 82001-3029
SUBDIVISION: Block: Lot: TX 46
PARCEL NUMBER: 001063013 Section: 6 Township: 30 N Range: 01 W
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 250 GAL PROP TANK - SAME SIZE & LOCATION
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 Bv: Date: Receipt: Approved/Date
Propane Tanks/Stoves $74.00 LYK 06/25/12 134939
Total: $74.00
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SITE VISIT REPORT
(PLOT PLAN)
JOB dI /74 2°I-L-!i✓�S DATE : D(//�/ t l� .
CONTACT: llll! ` /
ADDRESS �0i2. Tei2 PHONE #: 7 TGe,.
DIRECTIONS y° FAX #:
Email
PLANNER:
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11--\, JUN252012
JEFFERSON COUNTY
DEPT.OF COMMUNITY DEVELOPMENT
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oN 4.5 °a, JEFFERSON COUNTY •
i • ' \� . DEPARTMENT OF COMMUNITY DEVELOPMENT
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'' 621 Sheridan Street• Port Townsend •Washington 98368
360f379-4450 360/379-4451 Fax
www.Co.jefferson.w6a.us/commdevelopment
Master Permit Application MLA; 00 (ILA
Project Description(include separate sheets as necessary):
c io. • 0 • PIT iark:—&II(40 , (C)CaheX
Tax Parcel Number: 0 0 l iv 0 7J 3 Property.Size: feet),
(acres/square q e )
Site Address and/or Directions to Property:
22c; ec.)2T�1Z t)Pi u3 'F02T a(K ► S6010
Property Owner(s)of Record: r3 fIS21 L-t.._t 0 6 c
Telephone:3-.1 mil— 2-S-(P 0 Fax: email:
Mailing Address: a-1 I 0 h0016, 0 J,� � �'1 C� o
Applicant/Agent(if different from owner): ` ' � ! p
-ii>de-1--a----
Telephone: y@5 5 7,7 Fax: 3 8 5 -,..1.;8 75; email: ,y S"'i'`d 130x1a-,-e. ,c.),.
Mailing Address: /O e.�'3 , kRay .,OR• PT . t/�G a c% i.,)A
What kind of Permit?(Check each box that applies 0 Lot or Road Segregation
DBuilding 0 Critical Areas Stewardship Pia ' " —�4
El Demolition Permit ❑Variance(Minor,Majors qr� BoR9(n s
❑ Single Family 0 Garage Attached/Detached El Conditional Use[C(a)i, (ta),ur e)"` �l r
❑ Manufactured Home 0 Modular - 0 Discretionary"D"or llni med Use Classification I ,
❑ Commercial* 0 Special Use(EsserhtiaTPUblic F oilit' s **
❑ Change of Use ❑ Boundary Line Adj S ' nt Jul, J 2012
❑ Address 0 Road Approach ❑Short Plat**
jtorne Business 0 Cottage Industry 0 Binding Site Plan 1
Propane El Plat** IEFFERSON COUNTY
El Sign •- ❑Planned Rural Re nts** •
O Allowed"Yes"Use Consistency Analysis 0 Plat Vacation/Alteration"*
O Stormwater Management ❑Shoreline Master Program.Exemption/Permit Revisions**
0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development**
Temporary Use ❑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 ereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATUf E�i�[��%f C� / Y Date` /d--6 //
By signing this application form,the owner/agent attests that the inforrnati 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,cowl costs, reasonable attorneys fees and
expenses which may in any accrue against Jefferson County as a result of or in consequence of the granting of this permit.
!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. Staff ss and right of entry will be assumed unless the applicant Inform he County in citing at the
r time of the qn th , :or sh nts p` r n ice. '
` .natur /. Pate: D> , ---
7 (
The action or actions Applicant will undertake as a result of the i uance.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. Ahy 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 t Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfer a rasp sibilit r ad sin to mplying with the ESA. The Applicant has read this disclaimer a signs and da s It below.
Signal Date:
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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 ER: PHONE: FAX:
Sit-, Slime vl t° (A,d ) 3aS- S7I7 (30 3 'S-SP75
MAILING ADDRESS: /C7 E 5C. ? pr p. N EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: S V1 5- * cYrI 7 Q 0 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
❑ Repair 0 Masonry SEP Permit#
❑ Demolition 0 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 FoodSirvice? Yes / No _
—Jf this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
I Underground Tank c T Above ground k Size of Propane Tank: _
I Heat Stove I Cook Stove T ooVtT dstove I Fireplace Insert I Hot Water Tank t Pellet Stove I Other
Is this 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 fo all property lines,buildings and septic system components,
including the reserve area. •
t�
1.L � �y.. ,yf
Square Footage Current Pro used O ,
j' lw ,4.
Main Floor Heated Wyk; k ,t.' EH Bld App Review:
t'' , fir.`h a.�r9 ya�2na Floor Heated 4, ` f r 7%, Consistency Review:
• ,,
Other Heated ,:il i` Base.fee:
Y v#�� 3 7
Mezzanine ,N 4 N. Additional Section:
i
Heated Basement gt.-4,
0,�t:a Plan Check fee:
1t4l� u-�r 3
Unheated Basement �",, ,a State Surcharge fee:
' Other Unheated- - 7 d Pot Water Review fee:
Garage/Carport eikkiA°t i• j SUBTOTAL
Decks + f4, ' ' 911/Rd Approach fee:
er y ,5..
Other J TOTAL $ 74
q{ , a , x, ; Receipt Number: 1 34Q3
.,x Cash/Check Number:
-4153
ESTIMATED COST(REQUIRED) Date:
•Fa/r market value of all labor and materials foundation to finish
Initials:
G:\PenmitCenter\###FORMS###\DRD FORMS\Current DRD Forme\Matter Permit Application 5-29-08.doc