HomeMy WebLinkAboutBLD1991-00075 Jefferson County Buildir�Depart t ment®P .0 . Box 1220* Townsend. WA 98368
I.,OCAT I ON :100ra.j!
SPECIFIC LOCATION SITE ADDRESS c/�rct of d..
POSTAL DISTRICT /SUBDIVISION lO c' �Z7+•k4�
LEGAL DESCRIPTION LOT g BLOCK DIVI ON TAX NUMBER
PARCEL NUMBER 6oJ 45 .) 1 / 4 SECTION
PLANNING AREA SECTION 7..0 TOWNSHIP 30 NORTH RANGE ( A)' WM
BUILDING INFORMATION Zoc3o
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
® SINGLE FAMILY KNEW BUILDING MAIN FLOOR 17e ...
❑ MOBILE HOME 0 ADDITION ZND FLOOR ,/
❑ MODULAR HOME ❑ ALTERATION BASEMENT 82-
❑ DETACHED/ATTACHED ❑ REPAIR CARPORT
GARAGE ❑ REPLACEMENT GARAGE 'IO
❑ WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI -FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
MOBILE HOMES
❑ COMMERCIAL SIZE _,...lu @ $40
❑ INDUSTRIAL
YEAR 0 @ $2 0
❑ HOTEL/MOTEL/DORMITORY
NUMBER OF UNITS MAKE $ t0
O OTHER - SPECIFY ESTIMATED COST OF $10
IMPROVEMENTS TOTALy.FAIR MARKET VALUE
UBC OCCUPANCY GROUP $ \SS.(Po v $ 4�.^� //_�
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FI, EL
M WOOD FRAME ❑ ELECTRICITY 0 COLLECTIV!. SOLAR
❑ MANUFACTURED 0 WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL 0 GAS 0 COAL
O REINFORCED CONCRETE ❑ OIL RJ OTHER - SPECIFY ew� utmp
❑ MASONRY ( WALL BEARING ) DIMENSIONS SS X 5 '
❑ OTHER
. NUMBER OF STORIES 2 TOTAL LAND AREA22z24
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE D I SPOSAL NUMBER OF PROPOSED BEDROOMS 'Y
O PUBL I C OR PR I VATE NUMBER OF EXISTING BEDROOMS
DK 1 ND I V I DUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM 3
APPROVED DATE -41 I ND I V I DUAL WELL NUMBER OF EXISTING BATHROOM
amion_
PUD TYPE OF WATER SUPPLY
O PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE ® PRIVATE ( NAME OF WATER SUPPLL . L \\
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
N. 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
NAME MAILING ADDRESS n ZIP TEL NO
OWNER Pe.lG�Scck/ 1�e:Sker �Fj`Y5" �1s�ova�o P,e( i�t Tdwtis,�..r.Y `tft ISS'.4.s-9y.
CONT Mew ta,:kle Co,.�-�. � o %. \l!1 2 S;\ve rc_cA W 9 3P�3 692-0s70
SPATE L C NSE NO
g`VV1 ,
1`-3e
Ate_ D . S!t��14 S� 1 O7 CO- /c"t4u.t
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
1 GNATURE OF APPLICANT APPL I ��t�l��ATE 1 RECE���M� � CHE� �E�R:.sOR CASH
APPROVED BY PER IT FEES//�s��//!!(( /��'M''�j(/ 'y✓mil (l,F-4�f44f-/'\J..s
BASE FEE INSPECTION
BLDG SURCHARGE PLANACHE K
73 ... F.
ENERGY SURCHARGE $ •'jr" TOTAL
911 NUMBER REFUND DATE DATE ISSUED
BUILDING OFFICIAL