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HomeMy WebLinkAboutBLD2013-00374 111113UILDING PERMIT APPLICADN BRD1e 003 4 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD13-00374 Received Date: 11/26/2013 SITE ADDRESS: 140 THOMAS DR PORT HADLOCK, 98339 OWNER: RICHARD A LISKE JR PHONE: KELLY A LISKE PO BOX 1479 PORT HADLOCK WA 983391479 CHALMER'S 2ND ADDITION SUBDIVISION: Block: Lot: PARCEL NUMBER: 942900802 Section: 3 Township: 29 N Range: 01 W CONTRACTOR: AMERIGAS PROPANE L P PHONE: 425-219-9972 2831 74TH DR NE MARYSVILLE WA 98270 Contractor's License AMERIPL055LL Expires 8/2/2015 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION INSTALL 120 GAL PROPANE TANK AND LINES TYPE OF WORK RES SQUARE FOOTAGE: TYPE OF IMP MEC MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: 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 11/26/13 145578 APPROVED Total: $228.00 NOV 2 6 2013 Jefferson County DOD firlemerWrinfn\fnrrnelR RI Il Ann RIr1 rn+ 11 P)AP 114 49 Ox Cad,. JEFFERScOUNTY 1t"C�.' / � •4 - ' j DEPARTMENT OF COMMUNITY DEVELOPMENT ` '4 621 Sheridan Street • Port Townsend •Washington 98368 4 360/379-4450 • 360/379-4451 Fax 16WIN Cs www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: Project Description(include separate sh-ets as necessary): ►-V ra.-i/L12. i S 5t/- T s` -�chi 5-1,, Tax Parcel Number: 2- '1 00 O 2 Property Size: 101 go (acres/square feet) Site Address and/or Directions to Property: 114D I kcs s -Dv. ?`f---l,- tct(o e.,T- (-act Z 3 3C Property nner(s)of Record: � q- 5 Q2L1R� q- / 1YY12 1//t -1 tit e-Nta..�t .t.,.�/-cC, Telephone:. (QO) ?01 —0 lP l i Fax: email: k" l l q I i b k'€klAsi4,Cp1vi Mailing Address: PO 'i0 X i r-'l 9' 1 P4- 1--MAc'{ (oC,K- (Lf different from owner): {�1 CAA 0- - L✓i r,�- Telephone(Q0)30( a 1.0 ( ( Fax: email: Mailing Address: }20 150 k (u 9ei P COC) _ 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 El Garage Attached/Detached ❑Conditional Use[C(a),C(d),or C]** ❑ Manufactured Home .❑ Modular - ❑ 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** Propane ❑Long Plat** ❑ Sign ❑ Plannea Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration** ❑Stormwater Management El Shoreline Master Program Exemption/Permit Revisions** ❑ Site Plan Approval Advance Determination(SPAAD)* El Shoreline Management Substantial Development** 0 Temporary Use El 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: 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 a• s =nd right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required I- - -ctions. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application th-, - ,, •- - prior notice. rr / Signature: !�� Date: (( 96 1 The action or actions A A icant 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 v'•la- 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 co .• .n•- with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable respon • adhering to and complying with the ESA. The Applicant has read this disclaime and s:,ns •nd dates it below. ll Signature: i —/ Date: .i itv G:\PemritCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc BUILDER STATEMENT S 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 CONTRA TOR OR MANUFACTURED HOME INSTALL R: PHONE: FAX: 0‘.()UV)CONTRA pYt��.,� - , � cry. ( ) ( ) 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: rLi New ❑ Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System ❑ Repair ❑ Masonry — SEP Permit# L 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 Propane Tank and/or Appliance Installation permit,mark all items below that apply: 1 Underground Tank i Above ground Tank Size of Propane Tank: 1 Heat Stove 1 Cook Stove i Woodstove 1 Fireplace Insert 1 Hot Water Tank 1 Pellet Stove i 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: 2"°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 feel- Garage/Carport SUBTOTAL Decks 911/Rd Approach fee: Other TOTAL: $ Receipt Number: 114(l Cash/Check Number: , 12-x1 S14-1/ ESTIMATED COST(REQUIRED) Date: / .Fair market value of all labor and materials foundation to finish / Z ' r 3 Initials: / 1/V G:\PermitCenter\###FORMS###\DRD FORMS\Current DRD Forms\Master Permit Application 5-29-08.doc >- • • CC m H = O Q LL. N _0 Z LL � O H O LJD Lf] O •• •• CV • Q (4- N — N CO -j LL1 O - tr J O O L C9 "O X CC 'O ++ a) Z C C-) C) O H Li! 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L 0- - O (0 CL S- C-) C0 X -F+ U 'O X 10 C"J CL 10 - -- (0 CI) F- F- X 4- F- CD CO CI- * * F- CC Contractors or Tradespeople Peter Friendly Page • Page 1 of 2 General/Specialty Contractor A business registered as a construction contractor with LEI to perform construction work within the scope of its specialty.A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance. Business and Licensing Information Name AMERIGAS PROPANE L P UBI No. 601619800 Phone 4252199972 Status Active Address 2831 74Th Dr Ne License No. AMERIPL055LL Suite/Apt. License Type Construction Contractor City Marysville Effective Date 6/13/1995 State WA Expiration Date 8/2/2015 Zip 98270 Suspend Date County Snohomish Specialty 1 General Business Type Limited Liability Partnership Specialty 2 Unused Parent Company Other Associated Licenses Specialty Specialty Effective Expiration License Name Type 1 2 Date Date Status AMERI**101BP AMERIGAS Construction General Unused 1/17/1990 5/1/1996 Archived Contractor GASSYE*112P7 GAS SYSTEMS Construction General Unused 10/27/1989 5/1/1991 Archived ENGINEERING Contractor CALGA**136RJ CAL GAS Construction General Unused 12/11/1987 5/1/1990 Archived Contractor CALGA**213NM CAL GAS Construction General Unused 8/14/1979 5/1/1988 Archived Contractor Business Owner Information Name Role Effective Date Expiration Date PRENTICE HALL CORP Agent 07/27/2011 AMERIGAS PROPANE INC Partner/Member 07/27/2011 SAMUEL, STEVEN ALAN Partner/Member 07/27/2011 MAUCH, ROBERT C Partner 06/13/1998 07/27/2011 GOMEZ, LUIS A Partner 06/13/1998 07/27/2011 KNAUSS, ROBERT H Partner 06/13/1998 07/27/2011 Bond Information Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date 2 SAFECO INS CO OF AM 5799215 06/08/2002 Until Cancelled $12,000.00 06/27/2002 Assignment of Savings Information No records found for the previous 6 year period Insurance Information Insurance Company Name Policy Number Effective Date Expiration Date Cancel Date Impaired Date Amount Received Date Ace American 19 Insurance HDOG27019869 07/01/2013 07/01/2014 $1,000,000.00 08/02/2013 Company Ace American 18 Insurance HDOG27010015 07/01/2012 07/01/2014 $1,000,000.00 07/01/2013 Company Ace American 17 Insurance HDOG25526636 07/01/2011 07/01/2012 $1,000,000.00 06/24/2011 Company 16 ACE AMERICAN HDOG24942570 07/01/2010 07/01/2011 $1,000,000.00 06/28/2010 INS CO 15 HDOG2493259A07/01/2009 07/01/2010 $1,000,000.0007/13/2009 https://fortress.wa.gov/lni/bbip/Print.aspx 11/27/2013 Contractors or Tradespeople Peer Friendly Page • Page 2 of 2 ACE AMERICAN INSURANCE CO 14 INS AMERICAN HD0G23743759 07/01/2008 07/01/2009 $1,000,000.00 06/23/2008 INDEMNITY INS 13 CO OF N HD0G23726701 07/01/2007 07/01/2008 $1,000,000.00 07/02/2007 AMERICA Summons/Complaint Information No unsatisfied complaints on file within prior 6 year period Warrant Information No unsatisfied warrants on file within prior 6 year period Infractions/Citations Information No records found for the previous 6 year period https://fortress.wa.gov/lni/bbip/Print.aspx 11/27/2013 • MECHANICAL AND DEMOLITION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD13-00374 Received Date 11/26/2013 SITE ADDRESS: 140 THOMAS DR Issue Date 11/26/2013 PORT HADLOCK, 98339 APPLICANT: RICHARD A LISKE JR PHONE: KELLY A LISKE PO BOX 1479 PORT HADLOCK WA 983391479 SUBDIVISION: CHALMER'S 2ND ADDITION Block: Lot: PARCEL NUMBER: 942900802 Section: 3 Township: 29N Range: 01W CONTRACTOR: AMERIGAS PROPANE L P PHONE: 425-219-9972 2831 74TH DR NE MARYSVILLE WA 98270 Contractor's License AMERIPL055LL Expires 8/2/2015 OWNER, RICHARD A LISKE JR PHONE: if different: KELLY A LISKE PO BOX 1479 PORT HADLOCK WA 983391479 PROJECT DESCRIPTION: INSTALL 120 GAL PROPANE TANK AND LINES Directions To Site: THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 11/26/2014. REQUIRED INSPECTIONS: Tank/Line/Appliance: "Jr L?PIS • FinalApproval: rc.— / —9- BUILDING INSPECTION HOT-LINE 379-4455. REQUESTS MUST BE RECEIVED BY 3 PM THE DAY BEFORE THE INSPECTION IS NEEDED. Office Hours 9:00 a.m. -4:30 p.m. Monday-Thursday HOT LINE AVAILABLE 24 HOURS A DAY \\tidemark\data\forms\F_BLD_Permit_Propane.rpt 11/26/2013 4S ON C r ° °�� JEFFERSON COUNTY b.tio.$ DEPARTMENT OF COMMUNITY DEVELOPMENT IswiN0,0 Date: // _ 21 Time Received: / / / am/C) on Tue. Wed. Thur. Fri. Date: BLD: / 3 — 37 j Contact Name: Owner: / Contact Number: 360 Address: 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 4Q.,,,,s ON c OS �O� JEFFERSON COUNTY N DEPARTMENT OF COMMUNITY DEVELOPMENT 1,,,,. S J/ Date: / -2 Time Received: am alp Mon. Tue. Wed. Thur. Fri. Date: BLD: i 3 - 37 41 Contact Name: Owner: R i L(s�& -) Contact Number: 360 301' 04;41 Address: ! 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DIMEN510N PROPERTI' !_INE . ^ _ _ . o CENTERLINE V I EL I STREET 0 0 Design Firm z Project Name Chnn4- T4 4-1n _ . . . . • •