HomeMy WebLinkAboutBLD1989-00565 L'_DING i,'ERMIT APPL'ICATLON
Jefferson County Building DepartrnenteP .O . Box 1220Wort Townsend. WA 98368
I' LOCATJ ONE
1
SPECIFIC LOCATION SITE ADDRESS -' �� �'i d, 4`.'� �
POSTALISTRICT'^ /SUBDIVISION �; �I
D
" " LEGAL DESCRIPTION LOTe.lo BLOCK DIVISION TAX NUMBER
t PARCEL NUMBER �%�4�! ' '"r',' 1 / 4 SECTION
PLANNING AREA SECTION , TOWNSHIP c_,:;) NORTH RANGE A/ 1 WM
BUILDING INFORMATION �/
' BUI DING TYPE TYP -$F IMPROVEMENT SQUARE FOOTAGENJ
SINGLE FAMILY NEW BUILDING MAIN FLOOR / -
I ❑ MOBILE HOME ❑ ADDITION 2ND FLOOR �L 7nP
❑ MODULAR HOME 0 ALTERATION BASEMENT
S /. 0 DETACHED/ATTACHED ❑ REPAIR CARPORT ]
CN �^i"7 GARAGE ❑ REPLACEMENT GARAGE /
CT- 0 WOODSTOVE ❑ WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY 0 RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS ! 6c9--C
^ 0 COMMERCIAL MOBILE HOMES
!0 ❑ INDUSTRIAL
SIZE / q� $35 �?
� { YEAR /� $ 1 6 /8[�
��J ❑ HOTEL/MOTEL/DORMITORY {
t �J NUMBER OF UNITS MAKE `�- ��0,, p& $8 3�' )
�� ❑ OTHER - SPECIFY EST[MAT COST OF W @ $8
IMPR EMENTS TOTAL A F11: MARKET VALUE
UBC OCCUPANCY GRO $ $ , <��
/r�J/� 1
SELECTED CHARACTERISTICS OF BUILDING
PR CIPLE TYPE OF FRAME I'RII IPLE TYPE OF HEATING FUEL
WOOD FRAME ELECTRICITY ❑ COLLECTIVE SOLAR
❑ MANUFACTURED ❑ WOODSTOVE ❑ PASSIVE SOLAR
❑ STRUCTURAL STEEL ❑ GAS ❑ COAL
❑ REINFORCED CONCRETE 0 OIL ❑ OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMENSIONS � � /(mod/ /' l
❑ OTHER - NUMBER OF STORIES C2-__--/OTAL LAND AREA
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUTiBER OF PROPOSED BEDROOM
I5e1)._ L i 7 0 UBL i C OR PRIVATE NUMBER OF EXISTING BEDROOMS
A PUBLIC
ND I V 1 DUAL ( SEPT 1 C ) NUMBER OF PROPOSED BATHROOA
APPROVED DATE ❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
MI/PUBLIC ( NAME OF WATER SUPPLY)
APPROVED DATE 0 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 0 YES ❑ NO
IDENTIFICATION
/} NAME w --'^s MAIL N G ADDRESS ZIP T E/ 1�LN O
OWNER / -OU / L ...���A ,8, �b_T f
�J 1 k2 YVI et) 7
CONT �'
S FATE LICENSE NO 1
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ARCH
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THE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
SIGNATUREF L 1 C% APPLICATION _[7ATE REC 1 PT ER CHECK NUMBER OR OR CASH
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APP VE■ ,BY PERMIT FFSS '� .;.,n Ct
''I BASE FEE I NSPECT I ON
® a di.~ BLDG SURCHARGE / C .VVPLAN CHECK
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JEFFERSON f, ENERGY SURCHARGE s TOTAL
PONNiN(, 0G DE .
&BiDG DFP ^9 I I NUMBER REFUND DATE DA ISSUED
BUILDING OFFICIAL �0)0 i
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1ING&BLDG DEPT
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