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Jefferson County Builo ng Department•P .O . Box 122Wort Townsend. WA 98368
r LOCATION �J 1
SPECIFIC LOCATION SITE ADDRESS , (7 %z-i ZO h
POSTAL DISTRICT --- /SUBD I S ION e(J/Me — Z—
LEGAL DESCRIPTION LOT 3 BLOCK DIVISION� / TAX NUMBER
PARCEL NUMBER ( /� 51 (y 72---1 / 4 SECTION 7
PLANNING AREA SECTION , TOWNSHIP ,23?-) NORTH RANGE C Ll / WM
BUILDING INFORMATION
BUI DING TYPE TYPE O IMPROVEMENT SQUARE FOOTAGE
SINGLE FAMILY BUILDING MAIN FLOOR / -'o _l)
❑ MOOILE HOME 0 ADDITION 2ND FLOOR
❑ DULAR HO 0 ALTERATION BASEMENT /�?- . r
..47
DETACHE ATTACHED 0 REPAIR CARPORT GARAGE 0 REPLACEMENT GARAGE "/!C�"f�
4
❑ WOODSTOVE ❑ WRECKING/DEMOLITION ' COMMERCIAL
❑ MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
❑ COMMERCIAL OBILE HOMES ��j ��
0 INDUSTRIAL SI �C=�•: a $40 /�(��}�
❑ HOTEL/MOTEL/DORMITORY YEAR ../ -,A a $2 0 `C" �-)
NUMBER OF UNITS MAKE Tim ra @ $10 40
❑ OTHER - SPECIFY ESTIMAT COS OF '@ $10
IMPR EMENTS TOTA7 0 11)2 ARKET VALUE
UBC OCCUPANCY GROUP $ $ �1
SELECTED CHARACTERISTICS OF BUILDING
PR CIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
WOOD FRAME 0 ELECTRICITY 0 COLLECTIVE SOLAR
❑ MANUFACTURED 0 WOODSTOVE 0 PASSIVE SOLAR
❑ STRUCTURAL STEEL 0 G S 0 COAL
❑ REINFORCED CONCRETE OIL 0 OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS
❑ OTHER - NUMBER OF STORIES / TOTAL LAND AREA A
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE F SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
0 LIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
N D I V I D UA L ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE
❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
_....r
PUD TY OF WATER SUPPLY
PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY)
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
[/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
r NAME • a MAILING/LE ADDRESS ZIP 7 TEL NO
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CONT ! 'S�7[TS( �CE(NJs� "� fd s(A) �.
ARCH
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THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
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SIGNATU- - -0 APPLICANT APP ICATION DATE T UMBER ICHECK NUMBER OR CASH
I I I r ^�%� I � nrv� REC 1
AP R• :/C 14E0 ERiMIT FEES
1 BASE FEE INSPECTION
APR 1 2T/ BLDG SURCHARGE kL,G PLAN CHECK
JA�raon County P/ ENERGY SURCHARGE $ 7� 1�)� TOTAL
tiiidin annin
g�epa"Menh g /1) '0" 9 1 1 NUMBER REFUND DATE DATE ISSUED
BUILDING OFFICIAL
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