HomeMy WebLinkAboutBLD1990-00363 (3U NG . 'ERMIT APPLICATION
Jefferson County Building DepartmenteP .O . Box 1220+Port Townsend , WA 98368
LOCATION SPECIFIC LOCATION SITE ADDRESS �1D�t/T�Q.�-1eey L.-0 We
POSTAL DISTRICT /SUBDIVISION AI. �.
LEGAL DESCRIPTION LOT IpO BLOCK DIVISION t TAX NUMBER 99D-44/0-/sc9
l PARCEL NUMBER 1 / 4 SECTION
PLANNING AREA / SECTIONJ TOWNSHIP > NORTH RANGE O 1C WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
M SINGLE FAMILY % NEW BUILDING MAIN FLOOR QQ 92.
❑ MO:.. ILE HOME ❑ ADDITION 2ND FLOOR❑ .MODULAR HOME ❑ ALTERATION BASEMENT /82
VDETACHED/ATTACHED ❑ REPAIR CARPORT
777TTT GARAGE ❑ REPLACEMENT GARAGE S®rp O,
❑ WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
MOBILE HOMES
❑ COMMERCIAL SIZE @ $40
• INDUSTRIAL YEAR $20
❑ HOTEL/MOTEL/DORMITORY MAKE
NUMBER OF UNITS t<J $ 1 0
❑ OTHER SPECIFY ESTIMATED COST OF $ 10
IMPROVEMENTS TOTAL FAIR MARKET VALUE
UBC OCCUPANCY GROUP $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
iel WOOD FRAME , ELECTRICITY ❑ COLLECTIVE SOLAR
/❑"-MANUFACTURED ❑ WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL ❑ GAS ❑ COAL
❑ REINFORCED CONCRETE U OIL ❑ OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS 7 X �❑ OTHER - a NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
PUBL I C OR PRIVATE NUMBER OF EXISTING BEDROOMS
❑ INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM-_-,
APPROVED DATE ❑ I ND I V I DUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
J PUBLIC ( NAME OF WATER SUPPLY) / d,P LvDCoK/44,4Tr.0 Cv.
APPROVED DATE U PRIVATE ( NAME OF WATER SUPPLY , '
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
' _ YES NAME OF ADJACENT WATER BODY
❑ NO �r�
APPROVED DATE BANK HEIGHT �s,.,� SETBACK ,5-7
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED ❑ YES ❑ NO
IDENTIFICATION
NAME • MAILING ADDRESS ZIP T E L NO
OWNER Lf/®G)® 1fDetet9
J' T Z.61 Oi4 L . _M3/S- 4f37-9.c2
CONT (y"IG/AC/7yrO406-7:-C!G S QI ,BL ole .0,3 Pa.t!7 L riL��7i may.
5 A 1 I c-E iSE NO
g52(19L,cc /?Q/''?7
ARCH 7-On ,s r-C�e G /i2/C) 744e..t/E".e �•�r .6,94 7••-
_ SP,g 77Z e, cii.9< ?_//- 343-47s/
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
SIGNATURE OF APPLICANT APPLICATION DATE RECEIPT NUMBER CHECK NUMBER OR CASH
APPROVED BY PERMIT FEES
BASE FEE INSPECTION
BLDG SURCHARGE PLAN CHECK
ENERGY SURCHARGE
P TOTAL
9 1 1 NUMBER REFUND DATE ( DATE ISSUED
BUILDING OFFICIAL
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