HomeMy WebLinkAboutBLD1987-00355 s.
Jefferson County Building rtment • County Court/ rc_, • Port Toi•rnst Wash. 9S3GS • 335-1310
N E
I. LOCATION: geographic name S W SIDE OF ROAD FEET
N E /3/ C IL/iiRef-L ROAD
S W FROM INTERSECTION OF ROAD AND
other specific location or landmark:
1---(
LEGAL DESCRIPTION:
Lot Block Subdivision
z7 r-, 1 (A
Tax Number '/.Section Section Township Range
II.TYPE AND COST OF BUILDING -
TYPE F IMPROVEMENT BUILDING TYPE MOBILITY
New building Single Family ❑New County Resident
❑Addition ❑Multi-Family Is this structure to serve the residential
❑Alteration number of units or commercial needs of those employed
❑Repair,replacement ❑Hotel,Motel, Dormitory at either the U.S.Navy's Trident or
e� number of units Indian Island Facilities?
❑Wrecking ❑ obile Home
*\
❑Moving (relocation/ Other—Specify ❑YES ❑NO
❑Foundation only
USE
OWNERSHIP
❑Full-time Residence
❑Private (individual,corporation, ❑Second Home: Recreation Cabin,etc.
ON— nonprofit institution,etc.) ,�7,�
El Public (Federal,State or local gov't.) UBC OCCUPANCY GROUP: ' `/ ❑Second Home: Future conversion to
Cr'''
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 building at industrial plant.
a. Electrical If use of existing building is being changed,enter proposed use.
b. Plumbing Z ()4?\.( = S7b is Li ( Q -
7
c. Heating,air conditioning
d. Other (elevator,etc.)
• TOTAL COST OF IMPROVEMENT $
III.SELECTED CHARACTERISTICS OF BUILDING '��
i
PRINCIPAL TYPE OF FRAME ,TYPE OF SEWAGE DISPOSAL / DIMENSIONS
1..i-' •Number of Stories.
NII ❑Masonry (wall bearing) ❑Public or Private /
•Total squar t of floor area,
'CO ❑Wood Frame ❑Individual (septic ta/nfc;etc.) all fl , ased on exterior
❑Structural steel / ensions
❑ TYPE OF WATER S I PLY •Total land area,sq.
ft.
Reinforced concrete 11
❑Public or pate company
❑Other—Specify J NUMBER OF OFF-STREET
r' ❑Individual'(well,cistern) PARKING SPACES
1 /t 1/ Enclosed
PRINCIPAL TYPE OF HEATING FUEL TYPE OFIREPLACE
/ Outdoors
CIGas •-''
tO
❑O' RESIDENTIAL BUILpf(VGS ONLY
Electricity Number of bedjdoms
Coal YPE OF MECHANICAL
Numb,gf of/ Full
❑Other—Specify
/ ba ooms
i ,
Partial
czZ IV. IDENTIFICATION- - •
-' Name Mailing Address—Number,street,city and State ZIP code Tel.
No.
1. CO IMYv,A]r-1 N�J e Jr� !�n e\. = 3 $`
Owner
Mt-1-Nko a\3� C3A --?,d . Z(-{o k.\rs,,b _p --R331 LE-7?
2.
Contractor State License No. I
OCJ N
3.
Architect
The owner of this r • g,and the undersigned agree to conform to all applicable laws.
Signature of app n1 Address Appli tion a
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PLANNING 'AREA FIRE DISTRICT SCHOOL DISTRICT WATER DISTRICT
APPROV D/BY J4� 7
//cL�
JEFF COUNTY HEALTH DEPARTMENT -
APPROVED BY: PERMIT FEE ISSUE DATE RECEIPT NUMBER
t, /-- - -a LI (R 7 S- a- ?
BUILD IN WIC Yt)
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