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
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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 $1,000,000.00 07/02/2007
AMERICA
Summons/Complaint Information No unsatisfied complaints on file within prior 6 year period
Warrant Information No unsatisfied warrants on file within prior 6 year period
Infractions/Citations Information No records found for the previous 6 year period
https://fortress.wa.gov/lni/bbip/Print.aspx 11/27/2013
•
MECHANICAL AND DEMOLITION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT#: BLD13-00374 Received Date 11/26/2013
SITE ADDRESS: 140 THOMAS DR Issue Date 11/26/2013
PORT HADLOCK, 98339
APPLICANT: RICHARD A LISKE JR PHONE:
KELLY A LISKE
PO BOX 1479
PORT HADLOCK WA 983391479
SUBDIVISION: CHALMER'S 2ND ADDITION Block: Lot:
PARCEL NUMBER: 942900802 Section: 3 Township: 29N Range: 01W
CONTRACTOR: AMERIGAS PROPANE L P PHONE: 425-219-9972
2831 74TH DR NE
MARYSVILLE WA 98270
Contractor's License AMERIPL055LL Expires 8/2/2015
OWNER, RICHARD A LISKE JR PHONE:
if different: KELLY A LISKE
PO BOX 1479
PORT HADLOCK WA 983391479
PROJECT DESCRIPTION: INSTALL 120 GAL PROPANE TANK AND LINES
Directions
To Site:
THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE.
THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR.
THE EXPIRATION DATE IS 11/26/2014.
REQUIRED INSPECTIONS:
Tank/Line/Appliance: "Jr L?PIS
•
FinalApproval: rc.— / —9-
BUILDING INSPECTION HOT-LINE 379-4455.
REQUESTS MUST BE RECEIVED BY 3 PM THE DAY BEFORE THE INSPECTION IS NEEDED.
Office Hours 9:00 a.m. -4:30 p.m. Monday-Thursday
HOT LINE AVAILABLE 24 HOURS A DAY
\\tidemark\data\forms\F_BLD_Permit_Propane.rpt 11/26/2013
4S ON C
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°�� JEFFERSON COUNTY
b.tio.$ 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: ! LW ' I CttoIA%Az5 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
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