HomeMy WebLinkAboutBLD2013-00319 UILDING PERMIT APPLICAON BLD13-00319
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD13-00319 Received Date: 10/8/2013
SITE ADDRESS: 107 NOLTON RD
NORDLAND, 98358
OWNER: RICHARD C DOREMUS PHONE:
CAROL N DOREMUS
20938 2ND AVE S
DES MOINES WA 981982910 NOLTON'S EAST PT
SUBDIVISION: Block: 4 Lot: 4+
PARCEL NUMBER: 975900402 Section: 29 Township: 30 N Range: 01 E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2013
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr INSTALL PROPANE TANK
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP MEC MAIN:
VALUATION ADD'L: HEAT TYPE: PRO
CODE EDITION: 2012 HEAT BASE: HEAT TYPE: HTP
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: 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
Permit $228.00 MEB 10/08/13 145438 F Total: $228.00 fr
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621 Sheridan Street • Port Townsend •Washington 98368
4 r+ 360/379-4450 . 360/379-4451 Fax
5, � www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
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Tax Parcel Number: or--+6-01 pO((C) 2._ . Property Size: acres/s uar
( q e feet)
Site Address and/or Directions to Property:
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Property Owner(s)of Record: ti/ - ..
Telephone: 2O1.0 - SoLf - cit-ig`i Fax: email:
Mailing Address: (v 1-- Poi ,,�, ��
Applicant/Agent(if different from owner):
Telephone: Fax: email:•
Mailing Address:
What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation
Suilding ❑ Critical Areas Stewardship Plan
❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use)
❑Single Family ❑Garage Attached/Detached ❑ Conditional Use[C(a), C(d),or C]**
❑ Manufactured Home .❑ Modular V ❑ Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑ Special Use(Essential Public Facilities)**
Change of Use ❑ Boundary Line Adjustment
❑ Address ❑ Road Approach ❑Short Plat**
❑ Home Business ❑Cottage Industry ❑ Binding Site Plan**
"ropane ❑ Long Plat**
❑ Plannea Rural Residential Development(PRRD)/Amendments**
❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration**
❑Stormwater Management ❑ Shoreline Master Program Exemption/Permit Revisions**
❑Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Substantial Development**
❑Temporary Use ❑Shoreline Management Variance
❑Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
[0 Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment
*May require a Pre-Application Conference ❑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 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 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 appijpation that he or s .nts prior notice.
Signature: .� ��. - Date: /0- ,r-
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 Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfe respo i ility f a hering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: Date: /() - - /,,5
G:\PermitCenter\###FORMS###\DRD FORMS\Current 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: Date:
GENERAL CONTRACTOR OR MANUFACTU HOME INSTALLER: PHONE: FAX:
S,, ,,,,....� � F A.,,.L ( ) ( )
MAILING ADDRESS: 1-Az. t _ EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: T PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New ❑ Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: _ Height: ❑ Individual System
❑ Repair ❑ Masonry SEP Permit# _
❑ Demolition ❑ 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 Food Service? Yes / No -
If this is a Pro•ane Tank and/or A••liance Installation •ermit mark all items below that a••1 :
i Underground Tank 1 Above ground Tank Size of Propane Tank:
1 Heat Stove 1 Cook Stove 1 Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove 1 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 Current Proposed For Office Use Only - Amount Revision
Main Floor Heated EH Bld App Review:
2m Floor Heated Consistency Review:
Other Heated Base fee:
Mezzanine Additional Section:
Heated Basement Plan Check fee:
Unheated Basement State Surcharge fee:
Other Unheated Pot Water Review fee:
Garage/Carport SUBTOTAL
Decks 911/Rd Approach fee:
Other TOTAL: $
Receipt Number:
Cash/Check Number:
ESTIMATED COST(REQUIRED) Date:
.Fair market value of all labor and materials foundation to finish
Initials:
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
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so DEPARTME F COMMUNITY DEVELOPIONT
Date: 945_2, Time Received: PO am413 Mon. Tue. Wed. Thur. Fr '
Date: 9 f ze,
BLD: /3- 003/9 Contact Name:
Owner: Contact Number: 360
Address: /67 fr1g-ra0 IUD 206
Notes:
Foundation Plumbing Framing Propane Tank Mechanical
Setbacks Under-ground Framing Under ground Furance
Footing Rough In Air Seal Above ground Gas
Stemwall Hydronic Exterior shear Exterior lines Oil
Straps Hot Water Htr Interior shear Interior lines Ducts
Post Hole Ventilation Appliance
Underfloor Gas/Wood stove
Man-Homes Insulation
Final Inspection
Setbacks Floor
Foundation Wall Address Posted
Block&Tile Ceiling
MECHANICAL AND DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD13-00319 Received Date 10/8/2013
SITE ADDRESS: 107 NOLTON RD Issue Date 10/8/2013
NORDLAND, 98358
APPLICANT: RICHARD C DOREMUS PHONE:
CAROL N DOREMUS
20938 2ND AVE S
DES MOINES WA 981982910 4+
SUBDIVISION: NOLTON'S EAST PT Block: 4 Lot:
PARCEL NUMBER: 975900402 Section: 29 Township: 30N Ranqe: 01E
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
1385-5875
Contractor's License SUNSHP*077QP Expires 1 1 7/
OWNER, RICHARD C DOREMUS PHONE:
if different: CAROL N DOREMUS
20938 2ND AVE S
DES MOINES WA 981982910
PROJECT DESCRIPTION: INSTALL PROPANE 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 10/8/2014.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: 1.401-1 ' f Zk /I
f
Q /e
FinalApproval: K
BUILDING INSPECTION HOT-LINE 379-4455.
REQUESTS MUST BE RECEIVED BY 3 PM THE DAY BEFORE THE INSPECTION IS NEEDED.
Office Hours 9:00 a.m. -4:30 p.m. Monday-Thursday
HOT LINE AVAILABLE 24 HOURS A DAY
\\tidemark\data\forms\F_BLD_Permit_Propane.rpt 10/8/2013