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¢SON co J0t1U I Coungliepartment of Community Develont
� 1 0 2003 0 621 Sheridan Street,Port Townsend WA 8 12-13601378-4450
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Project Description: e"-er, / ( c� or"� VA .
Building Type: Project Type: Frame Type:
A Single Family j New >9 Wood
❑ Garage Attached/Detached ❑ Addition ❑ Steel
Modular ❑ Alteration/Remodel ❑ Concrete
❑ Commercial ❑ Repair ❑ Masonry
❑ Multi-family/#of Units ❑ Demolition ❑ Other
❑ Industrial
❑ Other:
Bathrooms: Bedrooms: Type of Sewage Disposal: Type of Heat:
Choose one:
Existing: /''' Existing: ' ❑ Sewer ❑ Community System ❑ Electricity ❑ Oil
Proposed: J.. (Z Proposed: ❑ Individual stem S
Total: t/� Total: Y ❑ Woods tove ❑ Propane
If not sewer,fill out the following: . Heat Pump
❑ Conventional ❑ Alternative ❑ Other
Permit# SEP
Water Supply:
❑ Private well ❑ Two Party Well❑ Public:Name of water system:
Square Footage: -7 ; For Office Use Only
Main Floor ) ( - s l Qlo Consistency Review 47.00
2ND Floor Base fee �j. 5'S
3rd Floor Plan Check fee-65% 1'7• 02
Htd Basement State Surcharge fee I[. '0
Unhtd Basement � � tt Subtotal 2(2 5- Y 7
Garage/Carport �c LE g32 16 Pot Water Review fee t'
Decks C�'CtYe 4G� 973a711/Rd Approach fee 1 i.
Commercial 3 3 C/. OTAL �-Q�' Lt
Industrial � Receipt# 0
Other Cash/Check# �L( DS
Total Valuation: Initials Sr./
Or Date1-0D ID`j
Estimated ost:
, o�
If within 0' of the Shoreline
Distance to Ba Water Mark ft.Bank Height ft.
By signing the application form,the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any
• omission of a material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue
against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and it's employees,representatives or agents for the purpose of application review and any required later inspections.
Access and right of entry to the at? - ' property or structure shall be requested and shall occur during regular business hours.
Signature . Dated` Y_. E j
OVER '_
H:HOME\PLNCNTR\INFOBLDG\FORMS\BLDpermitApplication 11-8-01