HomeMy WebLinkAboutBLD1989-00459 (3UILLG 'ERMIT APPLICATION
Jefferson County Building DCpartment.P .O . Box 122OsPor Townsend. WA 98368
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LOCATION_ ,j i ( (a-44M �-^.SPECIFICC LOCATION S ► TE ADDRESS
POSTAL DISTRICT /SUBDIVISION
LEGAL DESCRIPTION LOT BLOCK DIVISION TAX NUMBER
PARCEL NUMBER 7G/ / 1 / 4 SECTION
PLANNING AREA (t) SECTION (,'= TOWNSHIP C' i_/ NORTH RANGE WM
BUILDING INFORMATION
BUILDING TYPE Ty E OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY NEW BUILDING MAIN FLOOR
❑ MOT? I LE HOME ❑ ADDITION
2ND FLOOR
❑ MO ULAR HOME 0 ALTERATION BASEMENT
TACHE ATTACHED 0 REPAIR C RT,
OODA 0 REPLACEMENT ,r" / l ).)
❑ WOODSTO -W - . - CI L t
0 WRECKING/DEMOLITION C MMERCI ' L
O MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
❑ COMMERCIAL MOBILE HOMES
❑ INDUSTRIAL SIZE ) q`� $35
0 HOTEL/MOTEL/DORMITORY YEAR Ca $ 16
UMBER OF UNITS MAKE / $B /�
Ly OTHER PECIFY ESTIMATED COST OF 6 �f $8 �!J
IMPROVEMENTS
$ITOTAMV)MARKET VALUE
UBC OCCUPANC GROUP $
SELECTED CHARACTERISTICS OF BUILDING
PR NCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
WOOD FRAME 0 ECTRICITY 0 COLLECTIVE SOLAR
MANUFACTURED WOODSTOVE 0 PASSIVE SOLAR
❑ STRUCTURAL STEEL 0 GAS 0 COAL
0 REINFORCED CONCRETE 0 OIL 0 OTHER - SPECIFY
❑ MASONRY ( WALL BEARING )
0 OTHER - DIMENSIONS
NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
/P( 0 PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
APPROVED DATE 0 1 ND 1 V 1 DUAL ( SEPT 1 C ) NUMBER OF PROPOSED BATHROOM
0 I ND I V 1 DUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
0 PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY)
+...........
c:; PLANNING DEPT . WITHIN SHORELINE JURISDICTION
�' 0 YES NAME OF ADJACENT WATER BODY
fir,
j �NO
APPROVED DATE BANK HEIGHT SETBACK
PUBLIC WORKS DEPT ROAD RIGHT-OF-WAY WIDTH
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED 0 YES ❑ NO
IDENTIFICATION
NAME ���)��y� ��f� �1\ / MAILING ADDRESS ZIP TEL NO
OWNER �4 „ / �r `, ) J� C I . l
CONT
STATE LICE NO T
ARCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
/SIJT
TORAPPLICANT
A PL 1 CAN DATE
/NY/ R ' CHECK N BE
OR CASH
,-, 4/ / �O
f APP O BY
P RMIT FEES
AP _ Ibie. OOBAS£ FEE INSPECTION
.;,,^ ,�,5 --BLDG SURCHARGE PLAN CHECK
.L "rl``H'I+N(M 'I Y ENERGY SURCHARGE / 6 {/ SD
`RIVININ11,N,RI11d�fife"s ! 6666 111 TOTAL
911 NUMBER ! REFUND DATE ( D TE IS ED
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