HomeMy WebLinkAboutBLD1989-00471 •ILDING ` 'ERMIT APPLICATION
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Jefferson County Building Department®P,. O . Box 122Port Townsend . WA 98368
LOCATION
SPECIFIC LOCATION,
OCATIONE SITE ADDRESS CZ/i1f 'Y) ,...)az...) 1 .
POSTAL DISTRICT 1 /SUBDIVISION
LEGAL DESCRIPTION LOT r< _ BLOCK DIVIS ON 'TAX NUMBER
PARCEL NUMBER c 1 / 4 SECTION
PLANNING AREA SECTION el TOWNSHIP NORTH RANGE / V� WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY ❑ NEW BUILDING MAIN FLOOR Z/—/—
❑ MOBILE HOME ❑ ADDITION 2ND FLOOR 1�
❑ MODULAR HOME ❑ ALTERATION BASEMENT
❑ DETACHED/ATTACHED ❑ REPAIR ' CARPORT
21,0e6GE ❑ REPLACEMENT GARAGE
WOODSTOVE ❑ WRECKING/ • MOLITION COMMERCIAL
❑ MULTI - FAMILY ❑ RELOCATI •N/MOVING INDUSTRIAL /
NUMBER OF UNITS
❑ COMMERCIAL MOBILE H•` ES
❑ INDUSTRIAL SIZE �. S
❑ HOTEL/MOTEL/DORMITORY YEAR VI V$ 16
NUMBER OF UNITS MAKE O A $8
❑ OTHER - SPECIFY EST MATED COST OF d`l/Jf @ $8
L, . Ir-ROVEMENTS L FAIR MARKET VALUE
UBC OCCUPANCY GROURIT
�t
i SELECTED CHARACTERISTICS OF BUILDING
j PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
e ❑ WOOD FRAME 0 E CTRICITY ❑ COLLECTIVE SOLAR
" 0 MANUFACTURED OODSTOVE
v-�• 0 PASSIVE SOLAR
te.2 0 STRUCTURAL STEEL 0 GAS ❑ COAL
0 REINFORCED CONCRETE ❑ OIL 0 OTHER - SPECIFY
+, 0 MASONRY ( WALL BEARING ) ' DIMENSIONS '
0 OTHER - NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
,� HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
O PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS
❑ INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE ❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
M..>a
PUD TYPE OF WATER SUPPLY
O PUBLIC ( NAME OF WATER SUPPLY
APPROVED DATE 0 PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
❑ 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 ❑ YES ❑ NO
IDENTIFICATION .. .
NAME MAILING ADDRESS ZIP TEL NO
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CONT
T'ATh L I ceNst Nu ___.,
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THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
TURE OF APPLICANT APPLICATION ATE REC IPT NUMBER CHECK NUMBER OR CASH
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APPROV t i PE MIT FEES
A P P �•►t� . BASE FEE INSPECTION
\��`'` 5
BLDG SURCHARGE PLAN CHECK
JUN 2 1 ins c�0
ENERGY SURCHARGE $ 5 TOTAL
AffE118001 6M1 Y
KAIuN*B MO ljfljf 9 1 1 NUMBER REFUND DATE SYrA E I SUED
BUILDING OFFICIAL /{�" /` 0