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BUILDING PERMIT APPLICATION
Jefferson CountY Building Departmenl . Couily Courthouse . Port Townsend,Wash.98368 . 385-1310
PERMIT FEE
S W FROM INTERSECTION OF---.- ROAD AND
ROAD
tu
ction Township% SectionTax
Sr{rdiYsioe2?40 6Do o
other specific location or landmark
LEGAL DESCBIPTIONI
NE
SW SIDE OF , FEET
ROAD
l. LOCATIONi geographic name
NE
II. TYPE AND COST OF BUILDING
MOB|l,rrY
tfl1r"* County Resident
ls this structure to serve the residential
or commercial needs of those employed
at either the U.S. Navy's Trident or
lndian lsland Facilities?
E ves F"
TYPE OF IMPROVEMENT
I Atteration
D Repair, replacement
[] Wrecking
f] Moving (relocation)
D Foundation only
E New building
Addition
f] Hotet, Motel, Dormitory
number of units
Ftrobite Home
D Otfrer - SPecify
number of units
BUILDING TYPE
)(sinsle Famity
f] Multi-Family
XFrt,n'n'" Residence
E Second Home: Recreation Cabin, etc.
f] Second Home: Future conversion to
permanent residence
USE
UBC OCCUPANCY GROUP:
$Priru,u (individual, corporation,
Anonprof it institution, etc.)
E pubtic (Federal, State or local gov't.)
OWNERSHIP
(Omit cents)Nonresidential - Describe in detail proposed use of buildings, e.9., food
ne shop, laundrv buildinq at hospital, elementary
school,'college, parochial school, parking garage for
office buildinq, office building at industrial plant
se of existing building is bEing changed, enter proposed use
Y
processing
ment store, rental
Cost of improvement... . . ... .
To be installed but not included
in the above cost
a. Electrical.
b. Plumbing.
c. Heating,airconditioning .... -.
d. Other (elevator, etc.). . .
TOTAL COST OF IMPROVEMENT
COST
a
o
TYPE OF SEWAGE DISPOSAL
! Public or Private
ndividual (septic tank
DIMENSIONS
o lJ umber of Storres
.Total square feet of floor area,
all floors, based on exterior
dimensions.
.Total land area, sq. ftTYPE OF WATER SUPPLY
fi'Publrc or pflvate company
I lndividual (well, cistern)
III. SELECTED CHARACTERISTICS OF BUILDING
PRINCIPAL TYPE OF FRATVIE
trtructural steel
! Reinforced concrete
E Other - Specify
! Masonry (wall bearing)
I Wood Frame
OutdoorsTYPE OF FIREPLACE
RESIDENTIAL BUI LDINGS ONLY
Number of bedrooms
Full..
Part ial
Number of
bathrooms
TYPE OF MECHANICAL
PRINCIPAL TYPE OF HEATING FUEL
n G"t
E oil
ftlectricitvE coat
E Ott er - Specify
IV. IDENTIFICATION.
ZIP code Tel. NoMailing Address - Number, street, city and StateName
Owner
te nse
2.
Contr
2
Architect
The owner of this building and the undersigned agree toconform to all appl icable laws
Application dateAddress
)h L4Ur,,
ntSignature of appl
u
SCHOOL DISTRICT WATER DISTRICTFIRE DISTRICTPLANNING AREA
APPROVED BY
JEFFERSON COUNTY HEALTH E)EPT
PERMIT NUMBERISSUE DATEAPPROVED BY
- La*5+8
G OFFICIAL 2o.oo
NUMBER OF OFF-STREET
PARKING SPACES
Enclosed
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