HomeMy WebLinkAboutBLD1990-00168 IJUlLU1Nb "LkItJ. l HF'NL1lHIILJU
Jefferson County Build • Department•P .O : Box 1220O rt Townsend. WA 98368
,LOCATION
SPECIFIC LOCATION SITE ADDRESS 4 C
POSTAL DISTRICT Ph. /SUBDIVISION PhI1 LpStO trnnAnte,
LEGAL DESCRIPTION LOT ( A)9 BLOCK DIVISION TAX NUMBER
PARCEL NUMBER q 8l'n/i(7 1 nos 1 / 4 SECTION
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PLANNING AREA SECTION c,L,. TOWNSHIP aq NORTH RANGE VW WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY XNEW BUILDING MAIN FLOOR
❑ MOL1ILE HOME ❑ ADDITION 2ND FLOOR
❑ MODULAR HOME 0 ALTERATION BASEMENT QO x a2
CETACHEDIATTACHED 0 REPAIR CARPORT
GARAGE 0 REPLACEMENT GARAGE
❑ WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
O MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS MOBILE HOMES
❑ COMMERCIAL
0 INDUSTRIAL SIZE @. $40
0 HOTEL/MOTEL/DORMITORY YEAR 0 @ $20
NUMBER OF UNITS MAKE �•4 $1 0
O OTHER SPECIFY ESTIMATED COST OF $10
IMPROVEMENTS TOTA,L4 FAIR ,MARKET VALUE
UBC OCCUPANCY GROUP $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
1= WOOD FRAME 0 ELECTRICITY ❑ COLLEC_„_X_.LVE-"'SO AR
❑ MANUFACTURED 0 WOODSTOVE SSIVE SOLAR
O STRUCTURAL STEEL 0 GAS 0 COAL
O REINFORCED CONCRETE E3OIL 0 OTHER - SPECIFY
O MASONRY ( WALL BEARING ) DIMENSIONS
❑ OTHER - NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
❑, PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
APPROVED DATE , INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
0 YES NAME OF ADJACENT WATER BODY
)4NO
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 ❑ YES 0 NO
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
OWNER _(1m LT'
t(IA en
CONT
STKTL L I CE'NSE NO
ARCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS,
SIGNATURE OF APPLICANT APPL I C,AT I O DATE IRECEIPT NUMBER I CHFACKsr MBER r CASH
? -1/.(n42/0 BY PERMIT FE S d)& ��/�+�1L
702 ( ()O BASE FEE INSPECTION
It SO BLDG SURCHARGE PLAN CHECK
ENERGY SURCHARGE ( Lc)
. \ ) TOTAL
911 NUMBER REFUND DATE DATE ISSUED
BUILDING OFFICIAL
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