HomeMy WebLinkAboutBLD2003-00275 0 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 #: BLD03-00275 Received Date 5/5/2003
SITE ADDRESS: 2481 ANDERSON LAKE RD#402 Issue Date 5/5/2003
CHIMACUM, 98325
APPLICANT: BEULAH M IMLAY PHONE: (360)385-9017
2481 ANDERSON LK RD
SPACE 121
CHIMACUM WA 98325
SUBDIVISION: EVERGREEN COHO ESCAPEE RESORT Block: Lot:
PARCEL NUMBER: 901101039 Section: 10 Township: 29N Range: 01W
CONTRACTOR: CENEX SUPPLY& MARKETING PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CENEXHS022NQ Expires 09/06/2004
OWNER,
if different:
PROJECT DESCRIPTION: Above Ground Propane Tank ONLY
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 05/05/2004.
REQUIRED INSPECTIONS:
[ ] Tank/Line/Appliance:
[ ,- FinalApproval: (--/D -3/-03
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
ILDING PERMIT APPLICAT.1 Review Type:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00275 Received Date: 5/5/2003
SITE ADDRESS: 2481 ANDERSON LAKE RD#402
CHIMACUM, 98325
OWNER: BEULAH M IMLAY PHONE:
2481 ANDERSON LK RD
SPACE 121
CHIMACUM WA 98325
SUBDIVISION: OsclOi9C§k@OICOHO ESCAPEE RESORT Block: Lot:
PARCEL NUMBER: 901101039 Section: 10 Township: 29 N Range: 01 W
CONTRACTOR: CENEX SUPPLY& MARKETING PHONE: (360)732-4585
PO BOX 518
AUBURN WA 98071-0518
Contractor's License CENEXHS022NQ Expires 09/06/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOr Above Ground Propane Tank ONLY
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:
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
Prop: Prop: Seismic Streams
Total: Total: Flood Way Floodplain
Routing Date: F&W Landslide
Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Permit $47.00 CJZ 05/05/03 56126
Total: $47.00
JEFFERSON COUNTY COMMUNITY•ELOPMENT,621 SHERIDAN ST,PORT TOWNSE•A 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 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?
YES NO
SITE ADDRESS(911#/Road Name):
‹.-1 / -1 ,"a% ).i .leWe,e. 4/. .cl--
f� p ZIP 97:3c25
9 DIGIT PARCEL ID NUMBER 7C1///,}/Z.)3 9
Legal Description:
Subdivision Name Block Lot(s)
Section Township North, Range ✓ WM
APPLICANT 717 fiyG(/ ` r PHONE eZ? V79— 7/✓3
MAILING ADDRESS ,-.2 '9 7 oG Pe = 4,...e-e. g..0-
ZIP
PROPERTY OWNER f 17 c fer ret-e PHONE
MAILING ADDRESS
,l� � ZIP
CONTRACTOR (1//y`/J / PHONE
MAILING ADDRESS R.a • l8
OJ'�/w1 f W k- 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.
APPLICANTS SIGNATURE Yq � � :�� DATE , / vj / /�..3
�f—1" FOR OFFICE USE ONLY 66
BASE FEE -t / RECEIPT# ^� 3 c0 /t*
CONSISTENCY REVIEW CASH/CK# `o(
TOTAL a DATE 5 / 5 / 03
*Underground Propane Tank applications require additional information to be submitted. 0 V E R
Please contact our office at 360-379-4450 if the back of this application is blank.
g:\permitcenter\forms\bldg forms\install-revised 10-23-02.doc