HomeMy WebLinkAboutBLD1997-00783 (f-2,,..,, p, • ,../1
, ,,,...4,
..
JEFFERSON COUNTY PERMIT CENTER, 621 SHERIDAN ST, PORT TOWNSEND WA 98368 PH: 360-379-4450
INSTALLATION PERMIT APPLICATION
WOODSTOVE PROPANE TANK PELLET STOVE OTHER
SITE ADDRESS:
91 1#/ROAD NAME
T ��,.
ZIP (/,- j,?a
9 DIGIT PARCEL ID NUMBERq 7/ *G' 6
APPLICANT /'7 tt//j/ c J- D C L Q. / Q PHONE
MAILING ADDRESS 4 a A Q,( 1
///.,, A. s ZIP % v��/ ^O`j���f
PROPERTY OWNER ,Q�/�//(// /�' �, D� / PHONE
MAILING ADDRESS d f,. R. GX ,�17
/"5 /P /'/v%(/n/V/ Li// /4, ZIP g', _ - a,- 1-`71.
CONTRACTOR ��� �%/ / /�� /� �"/ i `' PHONE N Fj �9(LJ
MAILING ADDRESS ') "S''- g ` 7 (Ai' )c L),
PaIZ 7- ToG/ E NL7 U/i; , ZIP
STATE LICENSE # \-' uk, K-QI,b q-Lf b.A, EXP. DATE >it 1 q e
FEDERAL I.D. #
APPLICANT SIGNATURE 1G` fC � '' � Ql��✓ DATE ✓ / / 9'�
FOR OFFICE USE ONLY ii
BASE FEE a-�+ RECEIPT l 45
I C315o
STATE SURCHARGE 4!50 GAS CK #
TOTALci DATE I Z / !
H:\HOME\PLNCNTR\FORMS\INSTALL.DOC 61,0 q ( - 0 C �3