HomeMy WebLinkAboutBLD1989-00403 IJILDING ,,'ERMIT APPLICATIONi
Jefferson County Buila lig Department•P .O . Box 122L ort Townsend. WA 98368
LOCATION /
SPECIFIC LOCATION SITE ADDRESS :-. )( �/L
POSTA DISTRICT-_ /SUBDIVISIO LL G �1LC� / i
LEGAL DESCRIPTION LOT. ` K
'k9LOC�K} I fD I/V S 1 ON TA NUMBER
PARCEL NU ER %) //(%-7 C/( 1 / 4 SECTION r
PLANNING AREA k U SECTION TOWNSHIP NORTH RANGE /a WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY NEW BUILDING MAIN FLOOR
MOF.1ILE HOME ❑ DITION 2ND FLOOR
MODULAR HOME 0 ALTERATION BASEMENT /
0 DETACHED/ATTACHED 0 REPAIR CARPORT
GARAGE 0 REPLACEMENT GARAGE
❑ WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
0 MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
r
NUMBER OF UNITS "
❑ COMMERCIAL MOBILE HOMES
SIZE ,� to $35
❑ INDUSTRIAL
0 HOTEL/MOTEL/DORMITORY YEAR 4 a $ 16
NUMBER OF UNITS MAKE $8
O OTHER - SPECIFY ESTIMATED COST OF @ $8
IMPROVEMENTS TO AL FAIR MARKET VALUE
UBC OCCUPANCY GROUP.ir' $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME \PRINCIPLE TYPE OF HEATING FUEL
O WOOD FRAME fi�' ELECTRICITY 0 COLLECTIVE SOLAR
~MANUFACTURED T❑�WOODSTOVE 0 PASSIVE SOLAR
tO ❑ STRUCTURAL STEEL 0 GAS 0 COAL
Q 0 REINFORCED CONCRETE 0 OIL 0 OTHER - SPECIFY
0 MASONRY ( WALL BEARING )
O OTHER DIMENSIONS
NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEA TH DEPA 'TMENT TYPE OF SEWAGE D I SP( a MBER OF PROPOSED BEDROOMS - ..L
K_ CA/ 3 0 PUBLIC OR PR LVAT.h._ C�7, NUMBER OF EXISTING BEDROOMS
Yt '? ND 1 V I D U ( S E PT 1 C ``7 NUMBER OF PROPOSED BATHROOM --..)
\ ' APPROVED DATE
W ❑ INDIVIDUAL NUMBER OF EXISTING BATHROOM_!
PU TYPE OF WATER SUPPLY
�� 0 PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY)
.mmummm
PLANNING DEPT , WITHIN SHORELINE JURISDICTION
0 YES NAME OF ADJACENT WATER BODY
❑ NO
APPROVED DATE BANK HEIGHT SETBACK
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
l�Ji /f NAME OF PUBLIC ROAD
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED 0 YES 0 NO
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
OWNER rnie.:47,(1/ 2 3 69&7- ... '2- 71 „,,
.iliooerry /-1 e-.606 -,;-'
CONT
STATE L I CL,Nbt. NO '
ARCH
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
SIG ATURE OF APPLICANT
�PPL I CANT APP`�I CAT ON DATE RECEIPT NUMBER CHECIlL.
NUMBER OR CASH
6T f yC/1, J47 / Il �C/ I 'a(D O`'I I '.
AP OVED BY (f
\ PERMCI_T_ FEES
A P ( \\ /. V / BASE FEE INSPECTION
1 .. .`,i
_ , v BLDG SURCHARGE 7 PLAN CHECK
R 1989 ENERGY SURCHARGE $76 S
! TOTAL
JffffIfSgN COUNTY
P 4 V4V.(atat;11fP; 9 1 1 NUMBER REFUND DATE I DAT IS
:2
BUILDING OFFICIAL
. Y. !d W/O 1 /77g'
Manufactured Home:
Year 1989 Make FUQUA Width 28 Length 4 9
Vehicle Identification Number 10353
Registered Owners:
ROY R. FOSS
Names BILLIE L. FOSS Signatures'
Legal Owners:
Names Signatures'
'SIGNATURES OF OWNERS INDICATE TERMINATION OF INTEREST IN THE MANUFACTURED HOME THROUGH TITLE PROVIDED BY CHAPTER 46.12 RCW AND
INDICATE INTENT TO PERFECT INTEREST IN THE MANUFACTURED HOME AS REAL PROPERTY WITH THE LAND HE/SHE/THEY OWN AND TO WHICH IT IS/IS
BEING AFFIXED.
Land to Which Manufactured Home is Being Affixed: ./.0/ Chen
Property Tax Parcel Number 901 104 014
Legal Description LOT 2 OF ROGERS SHORT PLAT
ROY R. FOSS
Owners' Names BILLIE L. FOSS Signatures'
2SIGNATURES OF OWNERS INDICATE CONSENT TO HAVE THE MANUFACTURED HOME ADDED TO THE REAL PROPERTY LISTED ABOVE.
Building Permit Office Certification:
A ` ; 17,1 H"' 3 f
I certify that the manufactured home has beer mice.:tot reel Popert°gr 's described above and/or building permit
number has been issued for the pur. 'se c •ng the manrfactured home to the land and will be
inspected upon completion. r i�
1. �� e� �� 1`� 1
NAME SIGNATURE �'LDi •• I _^t� , v 4 _1,,, DATE PHONE NUMBER
u 3u,L y ,sIt Ft OZOli
County Auditor/Agent Licensing Office Approval: (Not for use by subagents)
I certify that the above application appears to have been completed correctly, and that the applicant has sufficient
documentation to proceed with the recording of this form.
NAME SIGNATURE OFFICE/CAAP OPERATOR NUMBER DATE
Recording Office:
I certify that this form has been recorded in the county records.
NAME SIGNATURE COUNTY DATE RECORDING NUMBER
Note: Every person who falsifies or intentionally omits material information required in an affidavit is guilty of a gross
misdemeanor punishable in accordance with RCW 9A.20.021.
TD-420-730 MFG HOME TITLE ELIM(N'1:901 Page 2 of 2
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