HomeMy WebLinkAboutBLD2003-00040 0
•
PROPANE/PELLET/WOOD STOVE & TANK INSTALLATION PERMIT
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD03-00040 Received Date 1/23/2003
SITE ADDRESS: 512 COUGAR RUN RD Issue Date 1/23/2003
QUILCENE, 98376
APPLICANT: MATT T PELLETIER PHONE:
TINA PELLETIER
PO BOX 848
QUILCENE WA 98376 T 21
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 702272015 Section: 27 Township: 27N Range: 02W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTPI983O6 Expires 09/26/2004
OWNER, MATT T PELLETIER PHONE:
if different: TINA PELLETIER
PO BOX 848
QUILCENE WA 98376
PROJECT DESCRIPTION PROPANE TANK INSTALLATION
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 01/23/2004.
REQUIRED INSPECTIONS:
[ ] Appliance: OK
� 1 '0.1' 'd3
[ FinalApprovaI: lN/G07•�0�7c� / -0 3
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. - 4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
is\F_BLD_Permit_Propane.rpt 10/29/19
40
BUILDING PERMIT APPLICATION BL view Type:
Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00040 Received Date: 1/23/2003
SITE ADDRESS: 512 COUGAR RUN RD
QUILCENE, 98376
OWNER: MATT T PELLETIER PHONE:
TINA PELLETIER
PO BOX 848
QUILCENE WA 98376
SUBDIVISION: Block: Lot: T 21
PARCEL NUMBER: 702272015 Section: 27 Township: 27 N Range: 02 W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTPI983O6 Expires 09/26/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIO PROPANE TANK INSTALLATION
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
MAIN:
VALUATION ADD'L: HEAT TYPE:
CODE EDITION: 1997 HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
OCCUPANCY: OTHER:
CONST TYPE: GARAGE: SHORELINE:
CONST TYPE: DECK: SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM:
PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Seismic Streams
Prop: Prop: Flood Way Floodplain
Total: Total: F&W Landslide
RoutingDate: ; Shoreline Aquifer
Z -3 Forest: Commercial gRural
Proximity Plat Conditions
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 PRB 01/23/03 52922
Total: $47.00
JEFFERSON COUNTY COMM•Y DEVELOPMENT,621 SHERIDAN ST,PORT TOND WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO
THIS INSTALLATION
Underground PROPANE TANK* �l Above Ground PROPANE TANK HEAT STOVE HOT WATER TANK
WOODSTOVE FIREPLACE INSERT PELLET STOVE COOKING STOVE
OTHER(Please Specify)
Is this appliance(htg stove, hot water tank,furnace, etc.)to be installed in a Manufactured/Mobile Home?
4 YES NO
SITE ADDRESS(911#/Road Name):
5-/.Z C' �19/e ,'ram
Gt%L CL=i�--"7 C \/'7> ZIP CC-?7•1_ /C`
9 DIGIT PARCEL ID NUMBER t c ',--J �--c 1
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range WM
APPLICANTJ !/ ,��LC L��rL (� PHONE 7c-,5 - 7�es<
MAILING ADDRESS P' C'x r'98 s�
-rCe/l__(ng Y$9 ` J/‘' ZIP
PROPERTY OWNER 514MI PHONE
MAILING ADDRESS
ZIP
CONTRACTOR Cal ',.‘/\ \ P1 PHONE .-S--(�
MAILING ADDRESS ID�nC ('�\kviv -,•c LAB... A
ZIP
STATE LICENSE# EXP.DATE
FEDERAL I.D.#
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material
falsehood or any omission of a material fact made by the applicant/owner 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 access and right of entry to Jefferson County and it's employees, representatives or agents for the purpose of application review and any
required later inspections. Access and right of entry to the applicant's property or structure shall be requested and shall occur during regular business hours.
APPLICANT'S SIGNATURE -..--22 `— .elr DATE / / 23/ OS
FOR OFFICE USE ONLY 52 n 2Z
BASE FEE ��•l� RECEIPT# `i
CONSISTENCY REVIEW 6 CASH 1/0/ Cj 260 7
TOTAL 47-00 DATE I /23/ 02
*Underground Propane Tank applications require additional information to be submitted. OVER
Please contact our office at 360-379-4450 if the back of this application is blank.
H:\HOME\PLNCNTR\INFOBLDG\FORMS\I NSTALL.DOC