HomeMy WebLinkAboutBLD1987-00353 LUILDL G f T, ,'( I ACI'LlL.-; ; iL:ti
Jefferson County BuildingOartment• County Courthouse • Port Towns.Wash.98368 • 385-1310
N E
I. LOCATION: geographic name S W SIDE OF ROAD ' FEET
N E �J
S W FROM INTERSECTION OF ROAD AND ( ROAD
' other specific location or landmark: o-o go--e....Le)
LEGAL DESC IPTION:
pJ,sui Lot Block Subdivision
\' ( 1--071- Tax Number Y.Section Sec ion o nship ange
II.TYPE AND COST OF BUILDING -
TYPE OF IMPROVEMENT BUILDING TYPE MOBILITY •
J - ew building Single Family ❑New County Resident
Ad Edition ❑Multi-Family Is this structure to serve the residential
❑Alteration number of units or commercial needs of those employed
�...- ❑Hotel,Motel,Dormitory at either the US.Navy's Trident or
❑Repair,replacement number of units ?
❑Wrecking Mobile Home
Indian Island Facilities.
❑Moving (relocation) ❑Other—Specify ❑YES El NO
❑Foundation only
USE
OWNERSHIP
❑Full-time Residence
❑Private (individual,corporation, El Second Home: Recreation Cabin,etc.
nonprofit institution,etc.) ,,,..
❑Public (Federal,State or local gov't.) UBC OCCUPANCY GROUP: '--- ❑Second Home: Future conversion to
permanent residence
COST (Omit cents) Nonresidential— Describe in detail proposed use of buildings,e.g.,food
• Cost of improvement $ processing plant,machine shop,laundry building at hospital,elementary
To be installed but not included school,secondary school,college,parochial school,parking garage for
in the above cost department store,rental office building,office buildi an .
a. Electrical If use of existing building is being changed,ente roposed e.
m
b. Plumbing 0 Cc \
c. Heating,air conditioning "� 1 '-- / (�, \ S/F.°
1 d. Other (elevator,etc.) 1(r t 00( tR A . e vVve 0\
J • TOTAL COST OF IMPROVEMENT $ / t +V`r
w/ III.SELECTED CHARACTERISTICS OF BUILDING - .
n S)
PRINCIPAL TYPE OF FRAME TYPE OF SEWAGE DISPOSA IMENSIONS
1-3 Masonry (wall bearing) Public or Private •Number of Stories
i •Total square feet of floor area,
❑Wood Frame ndivi septic tank c.) all floors,based on exterior
(Structural steel dimensions
❑Reinforced concrete TYPE OF WATER SUPPLY •Total land area,sq.ft.
❑Public or private company
Other—Spe fy I r NUMBER OF OFF-STREET
���V ❑Individual (well,cistern) PARKING SPACES -
t l Enclosed
PRINCIPAL TYPE OF HEATING FUEL TYPE OF FIREPLACE
❑Gas Outdoors
'.. ' ❑ it RESIDENTIAL BUILDINGS ONLY
—. ' electricityI
Number of bedrooms
❑Coal TYPE OF MECHANICAL
Number of Full
❑Other—Specify bathrooms
• Partial
IV. IDENTIFICATION- - •
Name Mailing Address—Num er,street,city and State ZIP code Tel.No.
1.
�!'�""'Owner _
2.
Contractor State License No.
3.
Architect
The owner of this building and the undersigned agree to conform to all applicable laws.
Signature f,a�pypyl�ic�ant,......}\
� /�( Address
�� n 4...,,,
'^ �> Appin date
/J "�Ou-+ (/lc ip/'`►^lam-�,
PLANNING AREA % FIRE DISTRICT SCHOOL DISTRICT WATER DISTRICT
APPROVED BY
JEFFERSON DEPARTMENT
BY: +��PEFjMIT FEE.78 ISSUE DATE SCE I.PT NUMBER CO
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BUILDING OFFICIAL )5�
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APPROVED
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