HomeMy WebLinkAboutBLD1995-00165 *JEFFERSON COUNTY BUILDING PERMIT APPLICATION
BUILDING TYPE IMPROVEMENT TYPE
SINGLE FAMILY ❑ NEW BUILDING
❑ MOBILE ❑ ADDITION 500+/500-
0 MODULARk/ ALTERATION
❑ GARAGE ATTACHED/DETACHED ❑ REPAIR
❑ WOODSTOVE ❑ DEMOLITION
❑ MULTI-FAMILY/UNITS ❑ RELOCATION
❑ COMMERCIAL
❑ INDUSTRIAL
❑ HOTEL/MOTEL/DORM/UNITS
❑ OTHER UBC OCCUPANCY GROUP
DESCRIPTION OF IMPROVEMENT:
SQUARE FOOTAGE PRINCIPLE TYPE OF HEATING FUEL
MAIN FLOOR *0 ELECTRICITY ❑ OIL
2ND FLOOR ❑ WOODSTOVE ❑ GAS
3RD FLOOR ❑ HEAT PUMP ❑ OTHER
HTD BASEMENT
UNHTD BASEMENT
CARPORT PRINCIPLE TYPE OF FRAME
GARAGE
DECKS WOOD ❑ MASONRY
COMMERCIAL ❑ MANUFACTURED ❑ OTHER
INDUSTRIAL ❑ STRUCTURAL STEEL
(5---THER
TOTAL VALUATION ( f
or i iJ
ESTIMATED COST MAXIMUM HEIGHT
❑ INSTALLED 19_
TYPE OF SEWAGE DISPOSAL: ❑ SEWER AfISEPTIC SYSTEM
SEPTIC PERMIT NUMBER
TYPE OF WATER SUPPLY: PRIVATE ❑ DRILLED WELL OTHER
PUBLIC ( CITY OTHER: NAME
❑ PUD STATE I.D.
NUMBER OF EXISTING BEDROOMS G NUMBER OF EXISTING BATHROOMS
NUMBER OF PROPOSED BEDROOMS ___S- NUMBER OF PROPOSED BATHROOMS
TOTAL NUMBER OF BEDROOMS ......57 TOTAL NUMBER OF BATHROOMS ['
IF WATERFRONT PROPERTY NAME OF ADJACENT BODY OF WATER `
BANK HEIGHT SETBACK
FRONT SETBACK SIDE SETBACKS / REAR SETBACK
SIGNATUREC7"� (-3,Qtjw\Ama DATE / — v
APPLICANT NAME (PLEAS)
FOR OFFICE USE ONLY
TYPE OF ACCESS RD
❑ Primary Arterial ❑ Secondary Arterial ❑ Collector ❑ Access
FOOTPRINT (incl decks over 30" from ground)
LOT COVERAGE (footprint divided by total
sq ft of property)
BASE FEE i � /c. 0 O /
PLAN CHECK U.j '% RECEIPT # t o ( 3
`{�
STATE SURCHARGE 4.50 DATE V6/(?S--
RADON KIT ; 10.00
TOTAL (.) .As CAS CHECK #
h:\HOME\PLNCNTR\FORMS\bldapp.frm