HomeMy WebLinkAboutBLD1990-00163 4
UILDING , 'ERMIT APPLICATIla ---:
Jefferson County Bulking Department*P .O . Box lirePort Townsend . WA 98368
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12CATION
SPECIFIC LOCATION SITE ADDRESS 0 - a i"--t
POSTAL DISTRICT , 4SUBDIVISION
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/awe/Lac:iv— WL--(1
LEGAL DESCRIPTION LOT 'I') BLOCK DIVISION TAX NUMBER
PARCEL NUMBER 1 / 4 SECTION
PLANNING AREA SECTION , TOWNSHIP ______NORTH RANGE R// WM
BUILDING INFORMATION
BUILDING TYPE PE OF IMPROVEMENT SQUARE FOOTAGE
0 INGLE FAMILY
-..,,MOBILE HOME 0 ADDITION 2ND FLOOR
0 MODULAR HOME NEW BUILDING
ALTERATION MAIN FLOOR
/
0
BASEMENT
O DETACHED/ATTACHED 0 REPAIR CARPORT
GARAGE 0 REPLACEMENT GARAGE
O WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
D MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
MOBILE HOMES of
O COMMERCIAL
SIZE •?..,?X ------.0 @ $40
O INDUSTRIAL
YEAR y, @ $20
O HOTEL/MOTEL/DORMITORY
MAKE $ io
NUMBER OF UNITS
O OTHER - SPECIFY Vi @ $ 10
ESTIMATED COST OF
IMPROVEMENTS TOTAL FAIR MARKET VALUE
UBC OCCUPANCY GRO 3
---74'7 $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE P INCIPLE TYPE OF FRAME TYPE OF HEATING FUEL
WOOD FRAME 0 ELECTRICITY 0 COLLECTIVE SOLAR
O MANUFACTURED 0 WOODSTOVE 0-PASSTV-E-SOLAR
O STRUCTURAL STEEL 0 GAS 0 COAL
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D REINFORCED CONCRETE LI 0-1-C- 0 OTHER - SPECIFY
O MASONRY ( WALL BEAR I NG )
• DIMENSIONS
O OTHER - -------
....... NUMBE_? O_E STGIII ES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS _77_,
PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
0)4 INDIVIDUAL ( SEPTIC )f
NUMBER OF PROPOSED BATHROOM APPROVED
-
APPROVED DATE
0 I ND I V I DUAL. WELL NUMBER OF EXISTING BATHROOM
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PUD TYPE OF WATER SUPPLY
D PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
O YES NAME OF ADJACENT WATER BODY
O NO
APPROVED DATE BANK HEIGHT SETBACK
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH _
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED 0 YES 0 NO
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
OWNER 764
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CONT
57A4L Lic=r—nu--
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ARCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
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S GNATURE Ory‘PPLIC 7T APPLICA ION DATE RECEIPT NUMBER CHECK NUMBER:DR CASH
' 4 q o6i 1 )2‘I .b
APPROVED BY PERMJ F5
3r —
BASE FEE INSPECTION
--
BLDG SURCHARGE PLAN CHECK
. .
, ENERGY SURCHARGE $ &S.-L.-
-- TOTAL
A911 NUMBER REFUND DATEr DATE ISSUED
BUILDING OFFICIAL
-.4