HomeMy WebLinkAboutBLD1989-00528 l3UILDI ``'ERMIT APPLICATION410
artment'P .0 . Box 122040Port "Townsend . WA 98368
arson County Building Dep J
LOCATION
10;:c.
�� S /SPECIFIC LOCATION SITE ADDRESS 1A LC/�` jjPOSTAL DISTRICT /SUBDIVISIWV
BLOCK DIVISION TAX NUMBER
LEGAL DESCRIPTION LOT p
PARCEL NUMBER I` / 1 / 4 SECTION •
PLANNING AREA
SECTION6 TOWNSHIP ORTH RANGE Wht
r
BUIL ING INFORMATION
BU LDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
SINGLE FAMILY VBUILDING MAIN FLOOR -70
❑ MOBILE HOME TION 2ND FLOOR
❑ MODULAR HOME DIALTERATION BASEMENT
O DETACHED/ATTACHED 0 REPAIR CARPORT
GARAGE ❑ REPLACEMENT GARAGE
❑ WOODSTOVE ❑ WRECKING/DEMOLITION ( COMMERCIAL
O MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
.` NUMBER OF UNITS r-n
SIZE MOBILE HOMES /
O COMMERCIAL $35 ! 7
❑ INDUSTRIAL YEAR $ 18
❑ HOTEL/MOTEL/DORMITORY MAKE 0 @ $8
NUMBER OF UNITS
i{` 0 OTHER - SPECIFY ESTIMATED COST OF 0 @ $8
1MPR EMENTS TOTAL.. FAIR MARKET VALUE
UBC OCCUPANCY GROUP $ �j� ( sj $
SELEC ED CHARACTERISTICS OF BUILDING
PR NCIPLE TYPE OF FRAME PRIN PLE TYPE OF HEATING FUEL
WOOD FRAME ELECTRICITY ❑ COLLECTIVE SOLAR
❑ MANUFACTURED 0 WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL 0 GAS 0 COAL
❑ REINFORCED CONCRETE ❑ OIL 0 OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS
❑ OTHER - NUMBER OF STORIES TOTAL LAND AREA
c\I DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS /--
t
C D P L 1 C OR PRIVATE NUMBER OF EXISTI NC; BEDROOMS,"
" Y ❑ I ND I V I DUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE D I V I DUAL WELL NUMBER OF EXISTIrJG BATHROOM
PUD TYPE OF WATER SUPPLY
❑ PUBLIC ( NAME OF WATER SUPPLY)
C -' APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY * w• ,.,R ,
PLANNING DEPT . WIT IN SHORELINE JURISDICTION
❑ ES 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 fl I cif
CONT y
' S"TATE L I CENSE ND ---fa---fa// G
ARCH A
THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS,
51 . AT T APP ICATION DATE RECEIPT UMBER CHECK NUMBER OR CASH
• CAN .�-� ( .o --"" -3 '
A OVED BY PERMIT 06 FEES .7t%L
AP -, Q �/ E , „r BASE FEE ))) INSPECTION
BLDG SURCHARGE PLAN CHECK
JEFFERSON COUNTY ENERGY SURCHARGE d - --7� TOTAL
PLANNING&BLDG DEPT P
9I1 NUMBER REFUND DATE DATE SSUED
BUILDING OFFICIAL
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