HomeMy WebLinkAboutBLD1987-00042 •ILDING , 'ERMIT APPLICATION 40
Jefferson County Building Department 'P .O . Box 1220t4Tort Townsend , WA 98368
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LOCATION _. �.. _ � ! /yam/ -----�-^
SPECIFIC LOCATION SITE ADDRESS " '�- z7 '1,(A z C�-7 2 .
POSTAL DISTRICT (--__ /SUBDIVISION
LEGAL DESCRIPTION LOT BLOCK DIVISION TAX NUMBER
C:PARCEL NUMBER C ' - (- C 1 1 / 4 SECTION
PLANNING AREA SECT ION TOWNSHIP { �NURTH RANG WI+1
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
MINGLE FAMILY ❑ NEW BUILDING MAIN FLOOR
OBILE HOME ❑ ADDITION 2ND FLOOR
❑ MODULAR HOME ❑ ALTERATION BASEMENT
❑ DETACHED/ATTACHED ❑ REPAIR CARPORT
GARAGE VEPLACEMENT GARAGE
!
❑ WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
❑ COMMERCIAL MOBILE HOME„ { $35
SIZE C< J C>)
❑ INDUSTRIAL YEAR t@�� $ 16
❑ HOTEL/MOTEL/DORMITORY MAKE ql $g
NUMBER OF UNITS
❑ OTHER - SPECIFY ESTIMATED COST OF 0 a $8
UBC OCCUPANCY GROI
IMPROVEMENTS T AL FAIR MARKET VALUE
� $
SELECTED CHARACTERN 'ISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
❑ WOOD FRAME ❑ ELECTRICITY ❑ COLLECTIVE SOLAR
• MANUFACTURED ❑ WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL ❑ GAS ❑ COAL
❑ REINFORCED CONCRETE U OIL ❑ OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS �;
❑ OTHER
NUMBER OF STORIES TOTAL LAND AREA t�l , ,
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS/
J�0/8 ❑ PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS_
54"'I-ND I V I DUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
APPROVED 6ATE VnI ND I V I DUAL WELL NUMBER OF EXISTING BATHROOM
`V'. ...,.,.... _.,._..... _.w..-__ --.. ___-._.,_—.- -_._.—....__....casr�crourer
PUD TYPE OF WATER SUPPLY
❑ PUBLIC ( NAME OF WATER SUPPLY___ ,
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY)
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑AYES NAME OF ADJACENT WATER BODY
`t' O
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
OWNER
AD1)0-1-1— �r
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CONT
S rA`I E L I C "7i-.m NU __.
ARCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
• S I GNATURE'y--iOFs PL 1, A * AFPL I CAT I N DATE RECEIPT UM NBER CUECI( NUTAHCR OR CASH
A -P••VED BY PERMIT FEES
i -- 7 BASE FEE INSPECTION
® Z . ZjC BLDG SURCHARGE PLAN CHECK
3
I444G 4 8, UfP= / 1 ,_w ENERGY SURCHARGE1d..'.r!/...L.-- _
TOTAL
/Q ___ 8 1 1 I UIYIB ER REFUND DATE DAT ISSUED
BUILDING OFFICIAL / )
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