HomeMy WebLinkAboutBLD1989-00500 I LDINGERMIT APPLICATION ,' • .
AN-4110
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Jefferson County Building Department*P .O . Box 122001Dort Townsend, WA 98368
r - LOCATION
SPECIFIC LOCATION SITE ADDRESSr f 7/ 44,,,wao 61C,A,
POSTAL DISTRICT /SUBDIVISION
LEGAL DESCRIPTION LOT BLOCK DIVISI TAX NUMBER
S
PARCELNUMBER (k1/. Z1j5 00 1 / 4 SECTION
PLANNING AREA SECTIONS TOWNSHIP , NORTH RANGE c \k,) WM
BUIL ING INFORMATION
BU LDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
SINGLE FAMILY 0 NEW BUILDING MAIN FLOOR
O MOBILE HOME 0 Ay-DITION 2ND FLOOR
O MODULAR HOME NX-ALTERATION BA. EmENT
0 DETACHED/ATTACHED 0 REPAIR CARPORT
GARAGE 0 REPLACEMENT GARAGE
O WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
O MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
\ • MOBILE HOMES
O COMMERCIAL 0 a
SIZE
O INDUSTRIAL —
YEAR 0 $ 16
O HOTEL/MOTEL/DORMITORY — —
MAK ' 2 $8
NUMBER OF UNITS ----
----
0 OTHER - SPECIFY ' @ "
ESTIMATED COST OF
cE.--- IMPROVEMENTS TO AL FAIR mARKET VALUE
UBC OCCUPANCY GROU
SELECTED CHARACTERISTICS OF BUILDING
. _
PR CIPLE TYPE OF FRAME
2WOOD FRAME/4
PRINCIPLE TYPE OF HEATING FUEL
0 El , TRICITY 0 COLLECTIVE SOLAR
O MANUFACTURED II ' •DSTOVE 0 PASSIVE SOLAR
O STRUCTURAL STEEL T GAS 0 COAL
O REINFORCED CONCRETE U OIL 0 OTHER - SPECIFY
—
O MASONRY ( WALL BEARING ) DIMENSIONS
t 7'
O OTHER - UMBER OF STORIES TOTAL LAND AREA43--k.
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYP - )F SEWAGE DISR, OST VumBER OF PROPOSED BEDROOMS
10,E BLIC OR PRIVATE NUMBER OF EXISTING BEDROOM
09NDIViDuAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOM
10
APPROVED DATE INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM—
PUD TYPE OF WATER SUPPLY
O PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE El PRIVATE ( NAME OF WATER SUPPLY
sj... PLANNING DEPT . WITHIN SHORELINE JURISDICTION
O YES NAME OF ADJACENT WATER BODY
IEEN'
4.7 .. .
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 0 YES 0 NO
IDENTIFICATION
NAME
i MAILING ADDRESS ZIP TEL NO
....,
OWNER 01.0„ ,),
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CO NT
- Eg I A`T E, LYE EiTTEE REEE 1 _ —
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ARCH
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THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE . ' :
7A277.7211-=
APPL I CAT TE RzE4E I PI GJMBER CHECK NUMBER •R CASH 11
....-....- 6:1
APPROVED BY P MIT FEES
BASE FEE INSPECTION
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BLDG SURCHARGE ,r,WI CHECK
ENERGY SURCHARGE TOTAL
' 0
911 NUMBER REFUND DATE DATE ISSUED
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