HomeMy WebLinkAboutBLD2021-00001DEPARTMENT OF COMMUNITY DE\IELOPMENT
621 Sheddan Sreet, Port Townsefld, W.L 98368
Tel: 360.379.4450 Fa-x: 360.379.4451
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E-mail: dcd@co.ieffetsoa.wa.us E)
IN
IMECHANICAL PERMIT APPLICAT ON
Steps in the Permit Process:rtitti.i0x CC i
iPr ff not M Nurr0r 't0t)[4rNT-Review required submittal items to ensure all information is completed prior to submitting application.-
-Mechanical Permits can be mailed into our office-and do not require an appointment.
-Fees are due at time of submittal, Mechanical permits are generally issued within 5 business days.
for Department Use Only
Related Application #s:
Receipt #:Date
Payment #:
ls this application for use in a Mobile / Manufactured Home?* lfYes: A permitfrom Washington State Department of Laborand lndustries, Iq! Jefferson County, is
required for appliances installed within a mobile/manufactured home, L&l - 350-4f7-270?* lf No: Complete this form and make an appointment to submit to Jefferson County Permit Tech 360-3794450
Required Submittal ltemr - for propane tank only
General Site plan - showing propane tank, lines, and distance from tank to all existing structures.
Required Submittal lt€ms - for roof mount Solar Panel installation only (Bround mounr complete cAM)
Complete first page and siBnature block only of Mechanical Permit Application.
A complete solar panel supplemental application.
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Site lnformatlon
AssessorTax Parcel Number: tOt f Ot O4Q
st" Aas\t. xLbG
Access (name of street(s) from which access will be gained: htdt rsc* / -l.z- (-za l. -,
Description of Work: ) ruh-c<-,H4 4 tt-a-/zJ,-
Property Owner
Name:
Add ress:
Phone #:.adrna
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Applicant/Contractor: Authorized AEent/Representative
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E-mail Address: arlio-0 d'!
-r:n-o -/'Nam e:
Phone #:
License #:
E-mail Ad d ress:
Expiration Date:
Mechanical Application
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I
JAN - 4 2!21
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Ot28
Heat Source
Property Owner
Sign atu re:Ilr'(t.^^-Print Name: t4gr(.- D a,vl t
lnstallation manual must be on site at time of inspection or a
re-inspection fee will be charged.
By siqninq this application form, the owneriagent attests that the information provided herein, and in any attachments,
is'tru5 and correit to the best oi hls, her or it6 knowledge. Any materlal falsehood or any omission of a material fact
made by the owner/agent with respect to this application packet may result in making any issued permil null and void.
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in
complianc-e wrth all applicable federal, state and county laws and regulations and I agree to provide access and right
of entry to Jetferson County and its employees. representatives or agents for the sole purpose of application review
and ariy required later inspections. Applicant may request notice of the County s intent to enter upon the property
for visits related to this application and subsequent permit issuance.
tr WoodE Heating Oil Propane*E Electric
lndicate Quantity of NEW Fixture Types Below
DescriptionQuantityFixture Tvpe
Bath Fan and/or Exhaust FanFan
clothes Dryer with Exhaust Ventclothes Dryer
Cook Stove, Range Hood Exhaust
Fireplace-Gas or Gas Log lnsertFireplace - Gas
Fireplace-wood, Wood Stove, or
Pellet Stove
Fireplace - Wood
Electric Furnace or HP +/- DuctingElectric Furnace
Propane Furnace +/- DuctinBPropane (LP) Gas Furnace
Water Heater - Gas
Gas Pipe System LPG/OilGas Pipe System
LP FuelTank (# g allons: tZb )Propa ne Tank
Heat Pump
* Propane is prohibited in
hazardous locations such as
basements or pits or
anywhere "heavier-than-
air" gas can unsafely
collect.
t Propane tanks over 125
ga llons require a minimum
setback of 10 ft. from
property line and buildings,
and a site plan must be
submitted with the
application showing the
setbacks. lf propane tank is
over 500 gallons, a site plan
is required to accompany
this application, and a
separate Fire Code approva I
is also required.
Gas WH Vent and Combustion Air
Air Conditioner
OFFICE USE ONLY
Building Permit Fees Single item only Tank, lines & appliance
Mechanical Peimit fee ltank swap, woodstove,furnace, roof-solar panel, etc )S19z.oo S192.oo
Prbpane - Lines, tank, and appliance (add'l 596.00)s96.oo
Project Scanning Fee 524.00 S24.oo
Technology Fee - 5%S10.80 s1s.60
Total Feesr s226.80 $327.60
lvlechanical Application
Cook Stove
Generator
I
Date: /_ *- Aoa t
+Additional fees may apply