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Jefferson County Building��partment.P .O . Box 12204P Townsend. WA 98368
LOCATION ,
SPECIFIC LOCATION SITE ADDRESS 1y t\\.�, � __,e
; �` •
POSTAL DISTRICT PT-
1 r /S U B� I V I S I O N t_....e;g�,> �-�C'- le,.y,,_,
LEGAL DESCRIPTION LOT BLOCK /54 DIVISION TAX NUMBER �f�
PARCEL NUMBER 41. l� l 9) 4"1q;) 1 / 4 SECTION
PLANNING AREA SECTION TOWNSHIP 2XDNNORTH RANGE - / /,.,..- WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY 11 NEW BUILDING MAIN FLOOR
❑ MOBILE HOME 0 ADDITION 2ND FLOOR
❑ MODULAR HOME 0 ALTERATION BASEMENT
,„„Ef-DETACHED/ATTACHED 0 REPAIR CARPORT
GARAGE 0 REPLACEMENT GARAGE 7j,0
❑ WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
0 COMMERCIAL MOBILE HOMES
❑ INDUSTRIAL SIZE a $40
❑ HOTEL/MOTEL/DORMITORY YEAR 0 $20
NUMBER OF UNITS MAKE -72; 0 a@ $10 .7 ,j.0
❑ OTHER - SPECIFY ESTIMATED COST OF 0 a $10
IMPROVEMENTS TOTAL FAIR MARKET VALUE
UBC OCCUPANCY GROU ; $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
❑ WOOD FRAME 0 ELECTRICITY 0 COLLECTIVE SOLAR
O MANUFACTURED 0 WOODSTOVE 0 PASSIVE SOLAR
"0 STRUCTURAL STEEL 0 GAS 0 COAL
❑ REINFORCED CONCRETE 0 OIL 0 OTHER - SPECIFY
O MASONRY ( WALL BEARING ) DIMENSIONS •
❑ OTHER - NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW .
HEALTH DEPARTMENT TYPE49F SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
❑ I4U B L I C OR PRIVATE NUMBER OF EXISTING BEDROOMS
❑ INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE ❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
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PUD TYPE 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 ❑ YES ❑ NO
IDENTIFICATION
,i NAME
�..1A '/1
I T MAILING ADDRESS ZIP
jc}; TEL NO
OWNER . -i'1(I - �' 170 O+N s:DI"". �h V ---'7S
CONT "LLL
I SIATt LICENSE Na
ARCH
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' THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS;
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SSINATURE OF APPLICANT APPLICATION DATE RECEIPT NUMBER CHECK NUMBER OR CASH
4 \TaX/V /t 31?u 469: ) -a- /3
APP ED BY PERMIT FEES
,L BASE FEE INSPECTION
BLDG SURCHARGE [(.} . PLAN CHECK
ENERGY SURCHARGE
_ TOTAL
911 NUMBER REFUND DATE DATE ISSUED
BUILDING OFFICIAL
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