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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 #: BLD03-00270 Received Date 4/29/2003
SITE ADDRESS: 640 BLACK BEAR RD Issue Date 5/1/2003
PORT TOWNSEND, 98368
APPLICANT: ROBERT M BUCK JR PHONE: (360)379-6996
DACIA D MORRISON BUCK
640 BLACK BEAR RD
PORT TOWNSEND WA 98368-9733 T 23
SUBDIVISION: Block: Lot:
PARCEL NUMBER: 001294007 Section: 29 Township: 30N Range: 01W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2004
OWNER, ROBERT M BUCK JR PHONE: (360)379-6996
if different: DACIA D MORRISON BUCK
640 BLACK BEAR RD
PORT TOWNSEND WA 98368-9733
PROJECT DESCRIPTION: PROPANE TANK& GAS PIPING
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 5/1/2004.
REQUIRED INSPECTIONS:
[ ank/Line,Appliance:
FinalApproval: 67?S t2.5
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
BLD03-00270
03UILDING PERMIT APPLIC iON Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00270 Received Date: 4/29/2003
SITE ADDRESS: 640 BLACK BEAR RD
PORT TOWNSEND, 98368
OWNER: ROBERT M BUCK JR PHONE: (360)379-6996
DACIA D MORRISON BUCK
640 BLACK BEAR RD
PORT TOWNSEND WA 98368-9733
SUBDIVISION: Block: Lot: T 23
PARCEL NUMBER: 001294007 Section: 29 Township: 30 N Range: 01 W
CONTRACTOR: SUNSHINE PROPANE PHONE: 385-5797
10853 RHODY DR
PORT HADLOCK WA 98339
Contractor's License SUNSHP*077QP Expires 11/17/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIO1, PROPANE TANK & GAS PIPING
TYPE OF WORK NON SQUARE FOOTAGE:
TYPE OF IMP NEW
VALUATION MAIN:
CODE EDITION: 1997 ADD'L: HEAT TYPE:
OCCUPANCY: HEAT BASE: HEAT TYPE:
OCCUPANCY: UNHEATED: #OF STORIES:
CONST TYPE: OTHER: SHORELINE:
CONST TYPE: GARAGE: SETBACK:
DECK: BANK HEIGHT:
SEWAGE DISPOSAL:
WATER SYSTEM: PARCEL TAGS: YES NO
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exist: Exist: Wetland Erosion
Prop: Prop: Seismic Streams
Total: Total: Flood Way Floodplain
Routing Date: F&W Landslide
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid Bv: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 MAM 04/29/03 56180
Total: $47.00
` JEFFERSON COUNTY COMMUNDEVELOPMENT,621 SHERIDAN ST,PORT TOW( D WA 98368 PH: (360)379-4450
INSTALLATION PERMIT APPLICATION
MARK ALL ITEMS BELOW THAT PERTAIN TO THIS INSTALLATION
Underground PROPANE TANK* Above Ground PROPANE TANK HEAT STOVE HOT WATER TANK
WOODSTOVE FIRREP,LACE/INNSERT PELLET STOVE COOKING STOVE
X OTHER(Please Specify) 6..
2 C`
Is this appliance(htg stove, hot water tank,furnace, etc.) to be installed in a Manufactured/Mobile Home?
YES NO
SITE ADDRESS(911#/Road Name):
(o'f0 6,I.
P i. l oW✓t4 QA-Q ZIP SJ(.,
9 DIGIT PARCEL ID NUMBER 0 u a 0 0 7
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range -7 am, WM
APPLICANT
�� G
PHONE / (O Cl ( )
MAILING ADDRESS
ZIP
PROPERTY OWNER ir� �"`" PHONE
MAILING ADDRESS
ZIP
CONTRACTOR (A-A'-S -- �PMl PHONE
MAILING ADDRESS I O O S �-{, r`4) O r / l
�G ' I� ( J� ZIP le 3 J
STATE LICENSE# t�ti ,k O 7 T9 r EXP.DATE /i/ ° y
FEDERAL I.D.# 9/ - / l7°1 c75
By signing the application form,the applicant/ov :ter 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 apr ocant/owner with respect to this application packet may result in this permit being null and void.
I turti,er agree to�3w�,',ngem`nif hold,armless 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 pro rty or structure shall be requested and shall occur during regular business hours.
APPLICANTS SIGNATURE 4 .O ( A 1 DATE 7/ / 7/ Q.
FOR OFFICE USE ONLY
v l (( /
BASE FEE RECEIPT# CJ(0
CONSISTENCY REVIEW CASH/CK# CI-2—C9
TOTAL DATE 'T/ )s O
*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.
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APR 292003
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DEPT. Of OPMENT