HomeMy WebLinkAboutBLD1995-00080 ' b`61 5-seal
**JEFFERSON COUNTY MOBILE HOME INSTALLATION PERMIT APPLICATION
BUILDING TYPE IMPROVEMENT TYPE UBC OCCUPANCY
fid! MOBILE 0 NEW BUILDING GROUP
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SIZE gV ) is 96�(�', 7i
YEAR 799,5
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MAKE GQL /(I (.-"P 7-
COST J Cr a
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DESCRIPTION OF IMPROVEMENT: JP( e. /4 e A� 7L 5 t� in C. & i 4A)r� 0 -`e-
TYPE OF SEWAGE DISPOSAL: 0 INSTALLED 19_
❑ SEWER Jk INDIVIDUAL SEPTIC
l NOT INSTALLED
TYPE OF WATER SUPPLY: PRIVATE 0 DRILLED WELL OTHER
PUBLIC ` CITY OTHER: NAME
❑ PUD STATE I.D.
NUMBER OF EXISTING BEDROOMS NUMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDROOMS 3 NUMBER OF PROPOSED BATHROOMS o2
TOTAL NUMBER OF BEDROOMS 3 TOTAL NUMBER OF BATHROOMS
IF WATERFRONT PROPERTY NAME OF ADJACENT BODY OF WATER
BANK HEIGHT SETBACK
SIGNATURE ;' DATE
APPLICANT NAME (PLEASE PRINT)
FOR OFFICE USE ONLY
PLANNING AREA FIRE DISTRICT SCHOOL DISTRICT
BASE FEE l a-s..._u D
PLAN CHECK 74- RECEIPT # f 46.S
-7
STATE SURCHARGEe, DATE �/ 3 / s---
TOTAL l c ' S'I) CASH/CEC# ('J 7 T(0
h:\HOME\PLNCNTR\FORMS\MOBILE.APP
Jeffe: Center Date
621 Sheridan Fee
Port Townsend vr. 38368 Rec #
CRITICAL AREAS QUESTIONNAIRE Ck #
Case #
Applicant Name "'JO firv'��-G-v--- 6(yetr_c-)
f`_
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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 ES NO
on your property or adjacent properties?
If YES, please describe:
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4. Are there any indications on any portion of the property or on any YES;ONO
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)
6. Does the site have steep slopes with little to no vegetation? NO
If YES, please describe:
7. Does the site contain high percentages of silt and/or very fine YES NO
sand?
If YES, please describe:
8. Does the site contain ground water seepage or springs near the YES NO
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 Date
FOR OFFICE USE ONLY
❑ Wetlands ❑ Seismic
CRITICAL AREAS ON OR ❑ Aquifer Recharge Area (zone ) ❑ Fish & Wildlife Area 1
IMMEDIATELYADJACENTTO SITE: ❑ Frequently Flooded Area ❑ Fish & Wildlife Area 2
❑ Erosion
❑ Landslide
Zone:
Parcel Size: Status:
Comprehensive Plan Land Use Designation: Reviewed by:
Community Plan: Date: