HomeMy WebLinkAboutBLD1995-00228 4 13 45---, o ar
*JEFFERSON COUNTY BUILDING PERMIT APPLICATION
BUILDING TYPE IMPROVEMENT TYPE
❑ SINGLE FAMILY ❑ NEW BUILDING
❑ MOBILE ❑ ADDITION 500+/500-
❑ _ MODULAR ❑ ALTERATION
l GARAGE ATTACHED/bETACHED I'b CI REPAIR
❑ WOODSTOVE l ❑ DEMOLITION
❑ MULTI-FAMILY/UNITS ❑ RELOCATION
❑ COMMERCIAL
❑ INDUSTRIAL
❑ HOTEL/MOTEL/DORM/UNITS
❑ OTHER UBC OCCUPANCY GROUP
DESCRIPTION OF IMPROVEMENT:
SQUARE FOOTAGE PRINCIPLE TYPE OF HEATING FUEL
MAIN FLOOR ri,:cJ)-
❑ ELECTRICITY ❑ OIL
2ND FLOOR ❑ WOODSTOVE ❑ GAS
3RD FLOOR ❑ HEAT PUMP ❑ OTHER
HTD BASEMENT
UNHTD BASEMENT
CARPORT PRINCIPLE TYPE OF FRAME
GARAGE
DECKS ❑ WOOD ❑ MASONRY
COMMERCIAL ❑ MANUFACTURED ❑ OTHER
..
INDUSTRIAL f
iJ' STRUCTURAL STEEL
OTHER %� •
TOTAL VALUATION j
Eor
S C/
lb)
ESTIMATED COST f�� J �"t MAXIMUM HEIGHT
d ❑ INSTALLED 19
TYPE OF SEWAGE DISPOSAL: ❑ SEWER ! SEPTIC SYSTEM
SEPTIC PERMIT NUMBER
TYPE OF WATER SUPPLY: PRIVATE il DRILLED WELL OTHER
PUBLIC ❑ CITY OTHER: NAME
❑ PUD STATE I.D.
NUMBER OF EXISTING BEDROOMS NUMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDRO NUMBER OF PROPOSED BATHROOMS
TOTAL NUMBER OF BEDROOMS TOTAL NUMBER OF BATHROOMS
/77
IF WATERFRONT PROPERTY-"NAME OF ADJACENT BODY OF WATER
BANK HEIGHT -'SETBACK
FRONT SETBACK DE BACKS / REAR TBACK
i 5
SIGNATURE ;` ��
DATE
APPLICANT NAME LEA PRINT)
/ FOR OFFICE USE ONLY
TYPE OF ACCESS RD
❑ Primary Arterial ❑ Secondary Arterial ❑ Collector ❑ Access
FOOTPRINT (incl decks over 30" from ground)
LOT COVERAGE (footprint divided by total
sq ft of property)
BASE FEE 1 k - 6 y
PLAN CHECK t4 '3• �' /RECEIPT # (' ' / 3
,I b�
STATE SURCHARGE 4. 0 `-C ' DATE - /
RAD9N Xi', .
TOTAL b . ( I ' ° CASH`CHECK (�I "`r/
h:\HOME\PLNCNTR\FORMS\bUdapp.frm
Jefferson County Permit Center
621 Sheridan St
Port Townsend WA 98368
UNIVERSAL PLOT PLAN
Fill in the following information as completely as possible.
Project Description: WY:44. 4 `
f �sd
9 Digit Parcel Identification Number (from your tax statement) 9A L q 4 0 Z• .
Site Address: Pi r) '91 1#/Road Name D Vlik
w Zip Coder' -S 6
kAl !
Legal Description: ��
Subdivision Name: SE dam- its( 5 i 7 2 f t lock Lot(s)
1
Section Township North Range WM
Parcel Size (square footage or acres)
�
,7,' ►° % 11
r 7,$5:1�
Applicant/Occupant % ' ? /1
,�--� ,� ,, ` t Phone ."� ` 57 �1
Mailing Address ) '
Property Owner (if different) ,, Phone
Mailing Address
Authorized Rep Phone
Mailing Address
Septic Designer Phone
Mailing Address Pi 0 t I '
General Contractor A ARIFUTELT Phon
es. :76"1 377 436 7o
Mailing Address 05 P) '
State License Number 4 Expiration Date
Architect Phone
Mailing Address
Loan Lender/Loan Holder Phone
Mailing Address , ,P—
FOR OFFICE USE ONL Y
Planning Area Fire Dist School Dist Zone
li:\...Plncnu1(orms\pblpin3