HomeMy WebLinkAboutBLD1989-00552 LIIILDING 'ERMIT APPLICATION
Jefferson County Build DepartmenteP .O . Box 1220•ort Townsend. WA 98368
LOCATION
SPECIFIC LOCATION SITE ADDRESS /2 ('' /2/J/�
POSTAL DISTRICT (ssX` /SUBDIVISION
LEGAL DESCRIPTION LOT BLOCK DIVILION TAX NUMBER/
PARCEL NUMBER �7Cfi. L-/C e� l 1 / 4 SECTION
SECTION TOWNSHIP .7 NORTH RANGE . (,-( ) WM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY ❑ NEW BUILDING MAIN FLOOR
❑ MOI.l l LE HOME ❑ ADDITION 2ND FLOOR
❑ MODULAR HOME ❑ ALTERATION BASEMENT
❑ DETACHED/ATTACHED ❑ REPAIR CARPORT
GARAGE ❑ REPLACEMENT GARAGE
'"WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS
❑ COMMERCIAL MOBILE HOMES
❑ INDUSTRIAL SIZE
p`� $35
❑ HOTEL/MOTEL/DORMITORY YEAR 1 $ 16
NUMBER OF UNITS MAKE 0 $8
❑ OTHER - SPECIFY ESTIMATED COST OF 0 @ $8
IMPROVEMENTS TOTAL FAIR MARKET VALUE
UBC OCCUPANCY GROUP $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
0 WOOD FRAME O'ELECTRICITY ❑ COLLECTIVE SOLAR
0 MANUFACTURED ❑ WOODSTOVE 0 PASSIVE SOLAR
❑ STRUCTURAL STEEL ❑ GAS ❑ COAL
❑ REINFORCED CONCRETE ❑ OIL 0 OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS
61/4\ / ❑ OTHER - NUMBER OF STORIES TOTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
❑ PUBL I C OR PRIVATE NUMBER OF EXISTING BEDROOMS
❑ I ND I VI DUAL ( SEPT IC ) NUMBER OF PROPOSED BATHROOM
APPROVED DATE ❑ I ND I VI DUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
❑ PUBLIC ( NAME OF WATER SUPPLY
APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY
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 Y r�1 11 MAILING y'� ADDRESS/�SS. ZIP T E L NO
OWNER \Y-144
1 U ((�0 1,C 1 p L )1lis l 1CQ CJ'
CONT
SPATE L I CETIbE NO I
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THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS,
76 SIGNATURE OF APPLICANT AP L I trAT 1 O�DATE IRECEIPT_NUMBER � CN���NU�ER OR CASH,-742 APPI6VED BY iERMIT FEES
E i � � C ; /C BASE FEE INSPECTION
BLDG SURCHARGE PLAN CHECK
A "4
ENERGY SURCHARGE ' iC
': TOTAL
911 NUMBER REFUND DATE 1 DAT 1(.11M
7 S D
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