HomeMy WebLinkAboutBLD1991-00326 UU. Lulivb AH'LiLA JU1v
Jefferson County Buildin Department.P..O . Box 1220.it Townsend. WA 98368
LOCAT I ON
SPECIFIC LOCATION SITE ADDRESS_ —"""— s-r,
POSTA.L��DISS T�TRIC f /SUBDIVISION 2 `` 4� 1
LEGAL DESCRIPTION LOT'L/,t) (IBLOC 55- DIVISION TAX NUMBER
PARCEL NUMBER (7/1,14 / 1 / 4 SECTION
PLANNING AREA SECTION TOWNSHIP 75C% NORTH RANGE tV. WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
t=SINGLE FAMILY -..NEW BUILDING MAIN FLOOR 1000
❑ MOBILE HOME 0 ADDITION 42ND FLOOR "`" •
❑ MODULAR HOME 0 ALTERATION ` BASEMENT
❑ DETACHED/ATTACHED 0 REPAIR t CARPORT
GARAGE ❑ REPLACEMENT BGARAGE ?55
❑ WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
❑ MULTI -FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS MOBILE HOMES
❑ COMMERCIAL
0 INDUSTRIAL SIZE @ $40
0 HOTEL/MOTEL/DORMITORY YEAR $20
NUMBER OF UNITS MAKE // /I�^} q`) $1 0
❑ OTHER - SPECIFY ESTIMATED COST OF V% f7 �I `� $1 0
IMPROVEMENTS _ TOTAL FAIR. MARKET VALUE
UBC OCCUPANCY GROUP $ —10 COQ $
f
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
�71 WOOD FRAME 0 ELECTRICITY ❑ COLLECTIVE SOLAR
❑ MANUFACTURED WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL 0 GAS ❑ COAL
❑ REINFORCED CONCRETE 0 OIL ❑ OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS
❑ OTHER - ' t ,_':-' ;'Y"
NUMBER OF STORIES �-'• TOTAL LAND AREA
i -PAR'PM=E-N1T:AL •:R£V'1 i�r11h
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED. BEDROOMS
❑ PUBL-1 C OR PRIVATE NUMBER OF EXISTING BEDROOMS
Yi ND I V I DUAL ( SEPT I C ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE ❑ I ND I V I DUAL WELL NUMBER OF EXISTING BATHROOM
PUD Ty OF WATER SUPPLY
[ UBL I C ( NAME OF WATER SUPPLY) ''' I)
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
E/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 0 NO
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
OWNER
1\04.1C ...E.i-pEZ -To'rk-` 61-6K44 (9,5--ke '-
r Ifb"_I i \. v�
CONT 6
STTAT$ L I C .NSE NO
+ 11
ARCH
THE OWN R OF THI ILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
S 1 GNA E Oi7" APP 1 ANT APPLICATION D ATE 77IPT NUMBER I CHE7 771R OR CASH
PPROVED BY PERMIT FEES
c
! / ' 4) BASE FEE INSPECTION
ejo
BLDG SURCHARGE (9 , ..s' PLAN CHECK
ENERGY SURCHARGE $ 1 / / 2 TOTAL
911 NUMBER REFUND DATE DATE ISSUED
BUILDING OFFICIAL