HomeMy WebLinkAboutBLD2003-00532 • •
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 #: BLD03-00532 Received Date 8/25/2003
SITE ADDRESS: 564 LARSON LAKE RD Issue Date 8/25/2003
CHIMACUM, 98325
APPLICANT: TOM SVORNICH PHONE: (206)842-9288
CHERYL SVORNICH
11388 OLYMPIC TERRACE NE
BAINBRIDGE ISLAND WA 98110 6
SUBDIVISION: MT TOWNSEND VISTA Block: Lot:
PARCEL NUMBER: 801105006 Section: 10 Township: 28N Range: 01W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 09/26/2004
OWNER, TOM SVORNICH PHONE: (206)842-9288
if different: CHERYL SVORNICH
11388 OLYMPIC TERRACE NE
BAINBRIDGE ISLAND WA 98110
PROJECT DESCRIPTION: ABOVE GROUND PROPANE TANK AND HEAT STOVE
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 08/25/2004.
REQUIRED INSPECTIONS:
['a" Tank/Line/Appliance9_C_. Q-i S-.0
['r FinalApproval:
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
I:\F_BLD_Permit_Propane.rpt 10/29/19c.
• BUILDING PERMIT APPL ATION BL Review T Ty y091
pe:
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD03-00532 Received Date: 8/25/2003
SITE ADDRESS: 564 LARSON LAKE RD
CHIMACUM, 98325
OWNER: TOM SVORNICH PHONE: (206)842-9288
CHERYL SVORNICH
11388 OLYMPIC TERRACE NE
BAINBRIDGE ISLAND WA 98110
SUBDIVISION: MT TOWNSEND VISTA Block: Lot: 6
PARCEL NUMBER: 801105006 Section: 10 Township: 28 N Range: 01 W
CONTRACTOR: MOUNTAIN PROPANE PHONE: (360)385-6883
265 CHIMACUM RD
PORT HADLOCK WA 98339
Contractor's License MOUNTP198306 Expires 09/26/2004
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOI` ABOVE GROUND PROPANE TANK AND HEAT STOVE
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: IF&W Landslide
6 Z-4o (C�3 Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Propane Tanks/Stoves $47.00 ZAN 08/25/03 58400
Total: $47.00
JEFFERSON COUNTY COMITY DEVELOPMENT,621 SHERIDAN ST,PORT T•SEND 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 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):
`t L-6 1- S Y-
C/em'1 vv.y ( ZIP CA '�a
9 DIGIT PARCEL ID NUMBER g 0/ — 1 Os - 6)2)6
Legal Description:
Subdivision Name m*- . "Ta W r1. A V Block Lot(s)
Section Township North, Range WM
APPLICANT C M (-d-1x LA 1 /V u n 1 c- PHONE -7 3 D Q(1; ,j 9
MAILING ADDRESS 5104. L.d--rSGs -0 Lk. R
tr vt„ w�— ZIP
PROPERTY OWNER PHONE
MAILING ADDRESS
ZIP
CONTRACTOR Mountain Propane PHONE 3g-C.- 6''g 3
265 Chllmacum Rd.
MAILING ADDRESS Port Hadlock,WA 98339
p ZIP p
STATE LICENSE# t. �-L 6o - - 0 7 ) a 7 �-- EXP.DATE / 'o7-15 ' 9
FEDERAL I.D.# /j'I()tint7 Z 4F3306
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 DATE '3 / 4 5/
L.� O FOR OFFICE USE ONLY 0
BASE FEE 1�• RECEIPT# �� •
I
CONSISTENCY REVIEW CASH/CK# 1� 1-L L
TOTAL ` kn," DATE o /2SAS
*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. 1111111.
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