HomeMy WebLinkAboutBLD1989-00481 1
N 13 -" DING 'ERMIT APPLICATION
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Jefferson County Buildin Department.P .O . Box122GffiF�L�-t Townsend. WA 98368
LOCATION } /�
SPECIFIC LOCATION SITE ADDRESS / 7! C /CGU /01 10
POSTAL DISTRICT (,\ a./SUBD I V I S I
LEGAL DESCRIPTION LOT BLOCK DIVISION TAX NUMBER _ `
14PARCEL NUMBER °�L ,, /fll G'!/ 16 1 / 4 SECTION
PLANNING AREA SECTION I ' TOWNSHIP ,�� NORTH RANGE c1A ) WM
BUILDING INFORMATION
BUILDING TYPE TYP OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY IdEW BUILDING MAIN FLOOR
❑ MOBILE HOME 0 ADDITION 2ND FLOOR
❑ IY190ULAR HOME ❑ ALTERATION BASEMENT
DETACHED/ATTAC Eq 0 REPAIR CARPORT
{7JGARAGE d ❑ REPLACEMENT GARAGE //t --2 4/qQ
O WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI -FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
❑ COMMERCIAL MOBILE HOMES {
❑ INDUSTRIAL SIZE @ $35
❑ HOTEL/MOTEL/DORMITORY YEAR /1 @ $ 16
MAKE i - a $NUMBER OF UNITS .:ce+ p � -.
❑ OTHER - SPECIFY ESTIMAT D COST OF 0 a $8
IMPR EMENTS TOTAL FAIL MARKET VALUE
UBC OCCUPANCY GROUP / $;of $ n/_
..._
'�� SELECTED CHARACTERISTICS OF BUILDING
PRI CIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL -----"WOOD FRAME 0 ELECTRICITY ❑ COLLECT SOLAR
0 MANUFACTURED ❑ WOODSTOVE ❑ PA E SOLAR
❑ STRUCTURAL STEEL ❑ GAS AAL
❑ REINFORCED CONCRETE 0 OIL ❑ OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIM: t" ONS
CI"- ❑ OTHER - N ER OF STORIES TOTAL LAND AREA
-, DEPARTMENTAL REV 1.F.W
HEALTH DEPARTMENT TYPE O SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
u ❑ P LIC OR PRIVATE NUMBER OF EXISTING BEDROOMS(/ (17/h I V I DUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM;
APPROVED DATE I ND 1 V 1 DUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
CSJ ❑ PUBLIC ( NAME OF WATER SUPPLY) a�
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY J
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
4
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
OWNER iirMIrjLAAOW
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ARCH
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LJL (.�, ;---4 .32-- ii333 /_5/ 911 L
THE- OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
SA/IGJIATU E OF APP ICANT A�PQPL I CCAT��ON DATE RECEIPT NUMBER CHECK NUMBER OR CASH
AA , 0' 0 PERMIT FEES
�c'�' 00
,� BASE FEE INSPECTION
i 1 19 1 \ ....„2.5.2._
BLDG SURCHARGE -_ PLAN CHECK
JEFFERSON COUNTY ENERGY SURCHARGE -517
PIFIUtIN( fk StOG DEPT
/// TOTAL
8 1 1 NUMBER REFUND DATE � -AT 1 SSU
BUILDING OFFICIAL _ _ �1 0,,. s - _
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