HomeMy WebLinkAboutBLD2021-00228 - 02 Supplemental ApplicationSupplemental SFR 1
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcd@co.jefferson.wa.us
SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt #: Date:
Related Application #s: Payment #:
Site Information
Owner Name: Assessor Tax Parcel #:
Type of Building
New Replacement Relocated
Addition Repair Demolition *
*A separate permit is required
Select One:
Single Family Residence Modular Other list
Proposed Building/Project
Number of floors # new bedrooms existing total bed
# new bathrooms existing total bath
Heat Source
Select all that apply:
Heat Pump Electric Heating Oil Wood Propane
Enter the square footage (sq/ft) that applies in each field:
Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office Use)
Residential / Commercial Main Floor
Residential / Commercial Second Floor
Additional Floors - heated / unheated
Basement - unfinished
Basement - finished space or habitable
Detached Garage - heated / unheated
Attached Garage - heated / unheated
Garage 2nd fl - unfinished storage
Garage 2nd fl - finished space or habitable
Carport - 2 walls or less
Deck - uncovered
Covered porch
Other (shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ $
Fair market value of project
4
4
1.00
$ 23,500.00
STO LLC
0.00
0.00
971,900,036
2800
Supplemental SFR 2
List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All Existing Buildings on Property Use
Builders Statement
The signer of this statement certifies that they are the Owners of the parcel referenced herein, that they are not licensed
contractors and that they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Print Name: Date: _____________
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is tr ue and
correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent
with respect to this application packet may result in making any issued permit null and void.
Signature: Print Name: Date:
For Department Use Only
Building Permit Fees
Building Base
Plan Check Review
Land Use Review $291.00
Septic Review $141.00
Potable Water $141.00
Technology/Scan $24.00
State Fee $6.50
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Technology Fee – 5%
Total Fees
Receipt # Date: Cash/Check/CC:
4/19/2021R Herbst