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BUI LDING PERMIT APPLICATION
Jefferson County Euilding Department. County Courthouse . Port Townsend, Wash.98368 . 385-1310
PERMIT EE
ROAD AND
Subdivision
Tax NJmber 7. Section Section
name
rfrtt tx
tr0
I. LOCATION
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ROM INTERSECTION O
or landmarkother specific
LEGAL D
Lot Block
NE
S W SIDE OF- ROAD , FEET
ROAD
I1. TYPE AND COS'OF BUILDING a.
E Ne* 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?
n ves ,8rvo
TYPE OF IMPROVE]MENT
E,lt"* building
D Addition
I-l Alteration
I I Repair. replacbment
I I Wreckino
E Moving (relocdtion)
D Foundation ohly
! Hotel, Motel, Dormitory
BUILDING TYPE
number of units
number of units
D Single Family
n Multi-Family
D Mobile Home
E Ottrer - Specify
OWNERSHIP
,EfPrivate (indivi,
nonprofit inst
D Prbtic (Feder,
iual, corporation,
tution, etc.)
l, State or local gov't.)UBC OCCUPANCY GROUP:
-
f-] Frtl-tin'e Residence
Et"."ond Home: Recreation Cabin, etc.
E Second Home: Future conversion to
permanent residence
USE
(Omit cents)
fiL
TOTAL COST OF IMPROVEMENTa
d. Other
conditioning
or. etc.)
Cost of improvement
To be but not included
in the above
COST
a
b. Plumbing.
c. Heating, ai
a. Electrical.
$ tl4rn
Nonresidential - Describe in detail proposed use of buildings, e.9., food
processing plant, rnachine shop, laundry building at hospital, elementary
school, secondary school, college, parochial school, parking garage for
department store, rental office building, office building at industrial plant.
lf use of existing building is being changed, enter proposed use.
III. SELECTED CHAI IACTERISTICS OF BUILDING -
2-TYPE OF SqWAGE DTSPOSAL
I Pubttc!r Private
\
! lndivrddgt (septic tank, etc.)t2//,
DIMENSIONS
o lJumber of Storres
. Total square feet of floor area,
all floors, based on exterior
dimensions.
.Total land area,sq. ft. ... ...'lO x loLO
PRINCIPAL TYPE OF FRAME
I Masonry (wall bearing)
.ElWood Frame
! Structural
! Reinforced
E Other - Speci
il*
l,l*
NUMBER OF OFF.STREET
PARKING SPACES
Enclosed
Outdoors
TYPE OF FIREPLACE
Al/b ^/*
tl'L
Dc".
E oir
D Electricity
fl coat
PRINCIPAL TYPE
y /rlortL
OF HEATING FUEL
E other - Speci
TYPE OF MECHANICAL
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RESIOENTIAL BUI LOINGS ONLY
Number of bedrooms
I
I
Full..
Partial
Number of
bathrooms
^t*IV. IDENTIFICATIO N
Name Mailing Address - Number, street, city and State ZIP code Tel. No.
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Oruner I i-,o-uQ-^,o . ()ast,4QnUC E88 otzt
2.
Con tracto r state Ltcense No
I
3.
Arch i tect
The owg{this bui ding and the undersigned agree to conform to all applicable laws.
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Address
PLANNING AREA IRE DISTRICT SCHOOL DISTRICT
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ISSUE DATE PERMIT NUMBER
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n m6lrid'v"t (well, cistern)
SUPPLYOF
private company
TYPE
E
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WATER DISTRICT-
JEFFERSON COUNTY
oFFtcrAL J
N
Dale Issued
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-1-1/15/8s
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