HomeMy WebLinkAboutBLD2014-00009 III
UILDING PERMIT APPLICJ ON BRLD1e 000009
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD14-00009 Received Date: 1/9/2014
SITE ADDRESS: 820 OLD HADLOCK RD
CHIMACUM, 98325
OWNER: JOHN G BELLOW PHONE: (425)218-7756
ROXANNE HUDSON
PO BOX 1015
CHIMACUM WA 98325-1015
SUBDIVISION: Block: Lot: T 76+
PARCEL NUMBER: 901112040 Section: 11 Township: 29 N Range: 01 W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**979OZ Expires 9/7/2014
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr INSTALL 250 GAL PROPANE TANK (replacing 2, 20gaI tanks)
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN:
VALUATION
CODE EDITION: 2012 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
Permit $228.00 MEB 01/09/14 145705 APPROVED
Total: $228.00 APPROVED
1 2;n'
Jefferson County DCL
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4j.�'SOx COL JEFFERS OUNTY 0 6 1 L — v°
w DEPARTMENT OF COMMUNITY DEVELOPMENT _
"' ` '4 621 Sheridan Street• Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�.q,87N 0� www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
Tax Parcel Number: OLLIii '2,014 O • Property Size: 474.% Ac (acres/square feet)
Site Address and/or Directions to Property:
I20 Q{dt l\oc \c CLI\v1a.Cv►wn. , WA 11C3zS
Property Owner(s)of Record: .��N C. Be-\\t‘Z
Telephone: Lj2.8–••Z.%if- ?9-S C Fax: email:84..116u. €.9 C410\eS?Leh•t Oyv..,,
Mailing Address: '?•0• -60x /O1S , (-Am v,,,C.4vv:i ti0141 '3
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies ❑Lot or Road Segregation
❑Building ❑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 - ❑ Discretionary"0"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**
0Propane ❑Long Plat**
Cyn ❑ 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
❑ 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:
�— AJP1
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 bei null and void.
I further agree to save,in,- '' and hold harrnle jJ= -r-• oun -•ainst all liabilities,judgments,court costs,reasonable attorney's fees and
expenses which may in - t accru- against f ers' o ty as a r: ult of or in consequence of the granting of this permit.
I further agree to pro-de .•• -s and ri;ht of ent, to J3 - ,-o County an• its employees,representatives or agents for the sole purpose of application
review and any regr ed I:te nspecti• s. Sta . a .- a d ight of en will be assumed unless the applicant informs the County in writing at the
time of the applicaf•n th - or she =nts prior '-
Signature: _ -�� V. • _ Date: 1"1
' Z 0 9
The action or actions Appl ant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered specie -n• •uld lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Sp s ,l "or"ESA."Jeff- -on Co_• . -• .es no assurances to the applicant that the actions that will be undertaken because this
permit has bee- is u . will not iolate t<A-: y indivi•,al,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)eve if yr - e in co pliance I h th -ffe rson Co my development code.The Applicant acknowledges that he,she or it holds individual
and non-tr. sfer-•I espons ility for.i,heri • . aid comp) ing with the ESA. The Applicant has read this disclaimer and gns and dates it below.
Signature: .
- // , Date: Z1q 1) 2.011-k
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 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: I Shoreline: Type of Sewage Disposal:
r, New 0 Wood r • Existing: b Sewer E.
0 Addition 0 Steel Proposed: Bank 0 Community System
Alteration/Remodel, ❑ Concrete Total: — Height , p In bvidual System
0
Repair ❑ Masonry — SEP permit#c _
L Demolition ❑ Other: Bedrooms: Water Supply:
Existing: _ Setback: 0 Private well ❑ Two
Type of Heat: Proposed: 0 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:
1 Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove 1 Cook Stove i Woodstove 1 Fireplace Insert 1 Hot Water Tank i 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 Off ice Use Only, Amount Revision
Main Floor Heated EH Bld App Review:
2"d 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: /(,(7,'
Cash/Check Number: 3s1
ESTIMATED COST(REQUIRED) Date: q //
.Fair market value of all labor and materials foundation to finish I/ `f
Initials:
•
G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc
Screen: 01 0 REAL PROPERTY MASTER Mode: INQUIRY
Auto Roll : OFF
Parcel # 000901112040 Geo Cd 290111204210 111
S1l T29 R1W Nbhd Cd 4240
TAX 76(LS PTN TAX 83)
SUBJ/CONS EASE W/JLT #539628
SUBJ/CC#08-2-000294-1 Loc ID
* Taxpayer Cd BELL 8500 BELLOW, JOHN G T/P Chg Dt 10/20/2008
* Title Owner T/P Chg Usr JODI
Tax Code 0211 Status TX TAXABLE Land Use 8100 OSAG
Affidavit 111879 Vol/Page / C/U Code A AGRICULTURAL
COMPLETE ADDRESS WINDOW
Taxpayer
BELL8500 JOHN G BELLOW
ROXANNE HUDSON
PO BOX 1015
CHIMACUM WA 98325-1015
Search Key
CMD 6: End Window CMD 7: End of Job
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#: BLD14-00009 Received Date 1/9/2014
SITE ADDRESS: 820 OLD HADLOCK RD Issue Date 1/9/2014
CHIMACUM, 98325
APPLICANT: JOHN G BELLOW PHONE: (425) 218-7756
ROXANNE HUDSON
PO BOX 1015
CHIMACUM WA 98325-1015 T 76+
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 901112040 Section: 11 Township: 29N Range: 01W
CONTRACTOR: C H S INC PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CHSIN**9790Z Expires 9/7/2014
OWNER, JOHN G BELLOW PHONE: (425) 218-7756
if different: ROXANNE HUDSON
PO BOX 1015
CHIMACUM WA 98325-1015
PROJECT DESCRIPTION: INSTALL 250 GAL PROPANE TANK(replacing 2, 20gaI tanks)
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 1/9/2015.
REQUIRED INSPECTIONS:
-..1. /Lin /Appliance: c ✓ L f -
FinalApproval:
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 1/9/2014
"Ox N JEFFERSON COUNTY
4.
DEPARTMENT OF COMMUNITY DEVELOPMENT
NSNrNG -
Date: /Z Time Received: /P/3 '"! m Mon. Tue. Wed. (ab Fri.
Date:
BLD: /11.19 Contact Name:
Owner: Contact Number: 360 L(2s--Zi217, ,C,
Address: gZp m 47) /MA-421.ouK 206
Notes: S -C/PE O!C /2C `/3(- d- 6/4K-ii
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
kw4SON °a.4\ JEFFERSON COUNTY
w `I DEPARTMENT OF COMMUNITY DEVELOPMENT
Date: /j) Time Received: 4221 am/7 Mon. Tue. /Wed. AM Fri.
(!((( Date: r7- f
BLD: /3—i/1 Contact Name: 111
Owner: Contact Number: 360 -' ta 4,?
Address: l 7/ /- -o L. 206
Notes: A 1 9 J
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
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