HomeMy WebLinkAboutAPPLICATION - BUILDING SUPPLEMENTALDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 1 Pax: 360.379.4431
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��sl1 r rl Goa SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only Receipt #: Date:
Related Application #s: Payment #:
Site Information
Owner Name: lllltleE; ,q ily ey\j v-� /3 „4;; _-f Assessor Tax Parcel #:
Type of Building
New
Addition
Select One:
Single Family Residence 4
Proposed Build!
Number of floors
Replacement X
Repair
Modular
0140
Relocated
Demolition
*A separate permit is required
Other list
total bed 2-
total bath
Heat Source
Select all that apply:
Electric 4 Heating Oil Wood Propane
Enter the square footage (sq/ft) that applies in each field:
# new bedrooms Z— existing Z
# new bathrooms 2 , S" existing Z
Structure Existing Sq/Ft
Proposed Sq/Ft
ICC Valuation (office Use)
Residential / Commercial Main Floor
�
1-7 � -3
Residential / Commercial Second Floor
5 / (p
Additional Floors - heated / unheated
Basement - unfinished
Basement - finished space or habitable
Detached Garage - heated / unheated
Attached Garage - heated / unheated
b Z
Garage 2nd fl - unfinished storage
Garage 2nd fl - finished space or habitable
Carport - 2 walls or less
7(0
Deck - uncovered
��'
��%
Covered porch
mac!
Other (shed, barn, pole bldg,etc.)
Estimated Cost of Project (Required): $ qOO oO
$
List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other):
All Existing Buildings on Property Use
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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.
SignatureI Print Name:I/I icd,r2f' *.. Date: �2-(zi zil
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true 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: �Date: 2IZI I/Zv Zv(_Print Name:
For Department Use Only
Building Permit Fees
Building Base
Plan Check Review
Land Use Review
Septic Review
Potable Water
Technology/Scan
State Fee
Other Fees
Shoreline Exemption
Zoning
Zoning
Other
New Address
Technology Fee — 5%
Total Fees
Receipt # Date; C
h Check CC:
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