HomeMy WebLinkAboutBLD1989-00378 V
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*DING ;, 'ERMIT APPLICATION
Jefferson County Building DepartrnentsP .O . Box 1220®•rt Townsend. WA 98368
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LOCAT 1 Orl �� � �/Z _
SPECIFIC LOCATION SITE ADDRESS �C'� � ' '1 -
POSTAL DISTRICT /SUBDIVIGION
4)3=001/PT I ON LOT BLOCK L7 1V1SA Or�t,_. FAX NUMBER
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PARCEL NUUUMBE "" . 1 / 4 SECTION S!
PLANNING AREA SECTION —, TOWNSHIP ?04 NORTH RANGE ✓, WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY ❑ NEW BUILDING MAIN FLOOR
❑ MOIJILE HOME 0 ADDITION 2ND FLOOR
❑ r-" OUI AR HOME [1 ALTERATION BASEMENT
❑ DETACHED/ATTACHED REPAIR ' CARPORT e
GARAGE - ❑ REPLACEMENT ` GARAGE
❑ WOODSTOVE ❑ WRECKING/DEMOLITION ' COMMERCIAL
• MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL ,
NUMBER or UNITS
❑ COMMERCIAL MOBILE HOMES Vi� 0 5 ' l I +�J
1
SIZE G `
C --. ❑ INDUSTRIAL
YEAR [f��� ��j $ 1 6
C�} ❑ HOTEL/MOTEL/DORMITORY MAKE VJ J $ B
NUMBER OF UNITS
M1OTHER P IFY $8
. ;,� g J� EST 1 MATED COST OFG�
t`� 1...,_; ' 1 ( U1 C ( A IMPROVE E-( S /C6
F 1 MARKET VALUE
! UBC OCCUPANCY GRO JP $ , C (' P ( 1
5c5c-) SELECTED CHARACTERISTICS OF BUILDING
{`
-�, PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL i- ~
WOOD FRAME ❑ ELECTRICITY 0 COLLECTIVE SOLAR
❑ MANUFACTURED ❑ WOODSTOVE 0 PASSIVE SQI�A"F�2
'' ? 0 STRUCTURAL STEEL ❑ GAS ❑ CO�.A��L',',.
❑ REINFORCED CONCRETE ❑ OILfHER - SPECIFY
SQ ❑ MASONRY ( WALL BEARING ) ' ' '�
D 1 MEraS 1-.L�iTS J w,f l� `X ,! •Acrc+t
❑ OTHER NUh1BER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT V TYPE OF SEWAGE DISPOSAL 1 NU'�Sr3LR OF PROPOSED BEDROOMS_�a,
Li PUBL I C OR PRI VA'TE; N6,,I YuLik OF LX.1si'ii`. a ir3ZDR.C. V37,
❑ INDIVIDUAL ( SEPTIC ) NUmrlER or FROI-'vsED BATHROOM_
APPROVED DATE 0 INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
❑ PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY MVs
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 T E L NO
OWNER �t//ege / ///' }/ / /�. ,C.7 .,[_Al / Y e' JO stl.V3 t'.G`c c{j
r
STAIMCorn. 1 A r.E• L 1 C EF1t;E R
/k.RCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGRIEE TO CONFORM TO ALL APPLICABLE LAWS,
SIGN URE OF A...4 CANT 1-LICAT ON RECEIPT NUMBER I CHECK NU B R OR CASH
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7
AP RO ED BY N PERMIT FE
i "BASE FEE _ INSPECTION
A P �� �f BLDG SURCHARGE PLAN CHECK
JUr
` 2 1994 ENERGY SURCHARGE $ TOTAL
JEFFERSON COUNTY 9 1 I NUMBER REFUND DATE DAT I SSUED
B1J1h Obi I I4FF i C I AL 7
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JEf FEBSOK COUNTY
PLANNING&BLDG DEi)1-
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