HomeMy WebLinkAboutBLD1989-00390 t % BUILD PERMIT APPLICATION
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Jefferson County Building Department®P .O . Sox 1220+Port Townsend. WA 98368
rLOCATION
SPECIFIC LOCATION SITE ADDRESS >Zi I 6 lu-y'S _- i.JJ\ ,
POSTAL DISTRICT- /SUBDIVISION ±Ii ' ( (1}Y 3
LEGAL DESCRIPTION LOT BLOCK DIVISION TAX NUMBER
PARCEL NUMBERX NUMBECI SECTION �p /
SECTION TOWNSH I Pi ('`), NORTH RANGE> / 0/ WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY ❑ NEW BUILDING MAIN FLOOR
❑ MOBILE HOME 0 ADDITION 2ND FLOOR
❑ MODULAR HOME ❑ ALTERATION BASEMENT
O DETACHED/ATTACHED ❑ REPAIR CARPORT
GARAGE ❑ REPLACEMENT GARAGE
\\WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MHULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS �'--
❑ COMMERCIAL MOBILE HOMES
0 INDUSTRIAL
SIZE----------- c� $3 5
s 't
❑ HOTEL/MOTEL/DORMITORY YEAR $ 16
NUMBER OF UNITS MAKE 0FF $8
O OTHER SPECIFY ESTIMATED COST OF Iu q� $8
1 IMPROVEMENTS TOTAL FAIR MARKET VALUE
UBC OCCUPANCY GROUP $ $
S SELECTED CHARACTERISTICS OF BUILDING
Cr PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
O WOOD FRAME ,ELECTRICITY ❑ COLLECTIVE SOLAR
❑ MANUFACTURED 0 WOODSTOVE 0 PASSI..VE SOLAR
0 STRUCTURAL STEEL 0 GAS
,9 _----fr COAL
❑ REINFORCED CONCRETE L7 91 0 OTHER - SPEC I F)'
0 MASONRY ( WALL BEA_$.-I-NG J DIMENSIONS
D ❑ OTHER NUMBER OF STORIES TOTAL LAND AREA
'�E1'ARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
❑ PUBLIC OR PRIVATE NUMBER OF EXISTING BEDRO9tAS-
❑ INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOS ED,,,)3A13jROOM
_
APPROVED DATE ❑ INDIVIDUAL WELL NUMBER OF EX,I..S':"": G BATHROOM
PUD TYPE OF WATER SUPPLY
❑ PUBLIC ( NAME OF WATER SL,J.PPLY)
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY)
PLANNING DEPT . WITHIN SHORELINE IRISDICTION
❑ YES NAME O,F%'ADJACENT WATER BODY
❑ NO
APPROVED DATE -WANK HEIGHT SETBACK
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPR ED DATE ROAD ACCESS PERMIT REQUIRED 0 YES ❑ NO
IDENTIFICATION
NAME MAILING ADDRESS - ZIP TEL NO
OWNE
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CONT
STATE LI Ct.NSE NO J
ARCH I
[ I
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS;
S TURE OF APP 1 j. APPLICATIpIN RATE RECEIPT U BER 1 CHECK NUMBER OR CASH
I
.. °'7 V 0 5'764/W8? .50. 4' /0 75
A ROVED BY PERMIT FEES
�~RECEIVD
�� E ,CV 1� BASE FEE INSPECTION
,5 ) 0 BLDG SURCHARGE PLAN CHECK
JAN 05 '1r,9
-—
ENERGY SURCHARGE ��
JEFFERSON COUNTY ` TOTAL
pi C' rir 9i RLOC FAT 9 1 1 NUMBER / REFUND
DATE DA-E IS
BUILDING OFFICIAL / �I
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