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*JEFFERSON COUNTY BUILDING PERMIT APPLICATION Gt
BUILDING TYPE IMPROVEMENT TYPE fdljt.' j
❑ SINGLE FAMILY . NEW BUILDING LI
❑ MOBILE 0 ADDITION 500+/500-
0 MODULAR -_:--- ❑ ALTERATION
Q GARAGE ATTACHE DETACHED ' 0 REPAIR _
❑ W000STOVE ❑ DEMOLITION
❑ MULTI-FAMILY/UNITS ❑ RELOCATION
❑ COMMERCIAL
❑ INDUSTRIAL
❑ HOTEL/MOTEL/DORM/UNITS
❑ OTHER ,A` UBC OCCUPANCY GROUP
DESCRIPTION OF IMPROVEMENT: ��y � f�_/J
SQUARE FOOTAGE / PRINCIPLE TYPE OF HEATING FUEL
MAIN FLOOR ❑ ELECTRICITY ❑ OIL
2ND FLOOR ❑ WOOOSTOVE ❑ GAS
3RD FLOOR 0 HEAT PUMP ❑ OTHER
HTD BASEMENT
UNHTD BASEMENT
CARPORT PRINCIPLE TYPE OF FRAME
GARAGE
j,
DECKS ❑ W000 ❑ MASONRY
COMMERCIAL ❑ MANUFACTURED ❑ OTHER
INDUSTRIAL ❑ STRUCTURAL STEEL
OTHER
TOTAL VALUATION `' ` \' OR ESTIMATED COST
❑ INSTALLED 19
TYPE OF SEWAGE DISPOSAL: ❑ SEWER SEPTIC SYSTEM
❑ NOT INSTALLED
TYPE OF WATER SUPPLY: PRIVATE 0/DRILLED WELL OTHER
PUBLIC CDCITY .-`""0. OTHAMF
--. ---IIT PUD STATE I.D.
NUMBER OF EXISTING BEDROOMS NUMBER OF EXISTING BATH M
NUMBER OF PROPOSED BEDROOMS(" NUMBER OF PROPOSED, MS
TOTAL NUMBER OF BEDROOMS \,_ . TOTAL NUMBER OF BATHROOMS
IF WATERFRONT PROPERTY NAME OF ADJACENT BODY OF WATER
BANK HEIGHT SETBACK
SIGNATURE /�-\(V!`•' --f�L:Cvf�, rie,) DATE �' r '-fit:- ,�/`/ 4=-f'
APPLICANT NAME (PLEASE PRINT) M CT- Q &IN E-Li--