HomeMy WebLinkAboutBLD1995-00134 E , ,9s-a/� y
*JEFFERSON COUNTY BUILDING PERMIT APPLICATION
BUILDING TYPE IIMPROVEMENT TYPE
❑ SINGLE FAMILY L11PR NEW BUILDING
❑ MOBILE ❑ ADDITION 500+/500-
O MODULAR ❑ ALTERATION
Fl GARAG ATTACHED/DETACHED ❑ REPAIR
❑ WOODSTOVE ❑ DEMOLITION
O MULTI-FAMILY/UNITS ❑ RELOCATION
❑ COMMERCIAL
❑ INDUSTRIAL
❑ HOTEL/MOTEL/DORM/UNITS
❑ OTHER UBC OCCUPANCY GROUP
`DESCRIPTION OF IMPROVEMENT: /6 ,Y 20 RUST ( J9 3"-e 6'ge,47
SQUARE FOOTAGE PRINCIPLE TYPE OF HEATING FUEL
MAIN FLOOR 0 ELECTRICITY ❑ OIL
2ND FLOOR 0 WOODSTOVE ❑ GAS
3RD FLOOR ❑ HEAT PUMP ❑ OTHER ftv/12_,
HTD BASEMENT
UNHTD BASEMENT
CARPORT r PRINCIPLE TYPE OF FRAME
GARAGE •,� ,,... ,9. C_ "s f
DECKS X WOOD ❑ MASONRY
COMMERCIAL ❑ MANUFACTURED ❑ OTHER
INDUSTRIAL ❑ STRUCTURAL STEEL
OTHER ,------- . ...-D
TOTAL VALUATION .
.0ESTIMATED COST e 3 5 MAXIMUM HEIGHT
❑ INSTALLED 1900 '??_..
TYPE OF SEWAGE DISPOSAL: 0 SEWER f <'SEPTIC SYSTEM
SEPTIC PERMIT NUMBER
TYPE OF WATER SUPPLY: PRIVATE ❑ DRILLED WELL OTHER
PUBLIC ❑ CITY OTHER: NAME
C PUD STATE I.D.
NUMBER OF EXISTING BEDROOMS UMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDROOMS BER OF PROPOSED BATHROOMS
TOTAL NUMBER OF BEDROOMS TAL NUMBER OF BATHROOMS
_
IF WATERFRONT PROPERTY NAME OF ADJACENT BODY OF WATER V��f'
//fin
BANK HEIGHT SETBACK {�/
FRONT SETBACK SIDE SETBACKS //J� REAR SETBACK
_SIGNATURE.441 _ . -" DATE ?—2-a—
APPLICANT NAME (PLEASE RINT) s if rb
FOR OFFICE USE ONLY
TYPE OF ACCESS RD
❑ Primary Arterial Li Secondary Arterial ❑ Collector ❑ Access
FOOTPRINT (incl decks over 30" from ground)
LOT COVERAGE (footprint divided by total
sq ft of property)
BASE FEE (93 `()
PLAN CHECK I U ,°13 RECEIPT # l 6 (-i'Co-Li -
y
STATE SURCHARGE 4.50 DATE 3/30-iI ,
RADON KIT 1 :>38
TOTAL L- • 4� HE CASH C
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h:\HOME\PLNCNTR\FORMS\bldapp.frm
6. Does the site have steep slopes with little to no vegetation? YES 7 NO
If YES, please describe:
7. Does the site contain high percentages of silt and/or very fine YES 5( NO
sand? /
If YES, please describe:
8. Does the site contain ground water seepage or springs near the YES XNO
surface of the ground?
If YES, please describe:
The applicant hereby certifies that all of the above statements and the information contained in any other
transmittals made herewith are true, and the applicant acknowledges that any action taken by Jefferson
County based in whole or in part on this application may be reversed if it develops that any such statement
or other information contained herein is false.
Signature AgdfjPi• Date - a Z
FOR OFFICE USE ONLY
❑ Wetlands ❑ Seismic
CRITICAL AREAS ON OR ❑ Aquifer Recharge Area (zone ) ❑ Fish & Wildlife Area 1
IMMEDIATELY ADJACENT TO SITE: ❑ Frequently Flooded Area ❑ Fish & Wildlife Area 2
❑ Erosion
❑ Landslide
Zone:
Parcel Size: Status:
Comprehensive Plan Land Use Designation: Reviewed by:
Community Plan: Date:
Jefferson County Permit Center Date
621 Sheridan Street Fee
Port Townsend WA 98368 Rec #
CRITICAL AREAS QUESTIONNAIRE Ck #
Case #
Applicant Name C Ti?Ue-I ,,ti L UicCIL 17
Building Application Land Use Application Shoreline Application
On-site Sewage Application Subdivision Application Other:
1 . Is there any standing or running water on the surface of the YES NO
property or on any nearby property at any time during the year?
If YES, please describe:
2. Has any portion of the property or any nearby property ever been YES NO
identified as a wetland or swamp?
If YES, please describe:
3. Are any willows, skunk cabbage, alders, or cottonwoods present YES ' NO
on your property or adjacent properties?
If YES, please describe:
4. Are there any indications on any portion of the property or on any YES V NO
nearby property of rockslides, earthflows, mudflows, or landslides?
If YES, please describe:
5. Please indicate which line best represents the steepest slope found
on your property. (Check appropriate box)
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(Questionnaire Continues on Back)