HomeMy WebLinkAboutBLD1989-00568 (3UI•NG 4'ERMIT APPLICATION
o CountyBuilding Department'P .O . Box 1220,Po•' Townsend. WA 98368
Jefferson 9
LOCATION
SPECIFIC LOCATION SITE ADDRESS
1
POSTAL DISTRICT SUBDIVISION
LEGAL DESCRIPTION LOT BLOCK[D !/ DIVIS IDN TAX NUMBER
PARCEL NUMBER // 0 a 1 / 4 SECTION 4,0
PLANNING AREA SECTION /I TOWNSHIP.. / NORTH RANGE J "' WM
BUILDING INFORMATION -
BUILDING TYPE TYP OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY erNEW BUILDING MAIN FLOOR
❑ MOBILE HOME 0 ADDITION 2ND FLOOR •
O MODULAR HOME ❑ ALTERATION BASEMENT
,
1SETACHE , ATTACHED ❑ REPAIR CARPORT
GARA 0 REPLACEMENT GARAGE
❑ WOODSTOVE 0 WRECKING/DEMOLITION COMMERCIAL
❑ MULTI - FAMILY ❑ RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS MOBILE HOMES
❑ COMMERCIAL $35
SIZE 0 `@
❑ INDUSTRIAL YEAR r�-
❑ HOTEL/MOTEL/DORMITORY MAKE C; „ 0 @ $86 2y4s
MBER OF UNITS
OTHER - SP CIFY ESTIM D COST OF @ $8
IMP VEMENTS TOT FAI MARKET VALUE
UBC OCCUPANCY GROUP $ $
SELECTED CHARACTERISTICS OF BUILDING
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
❑ WOOD FRAME 0 ELECTRICITY ❑ COLLECTIVE SOL
O MANUFACTURED 0 WOODSTOVE 0 PASSIV AR
O STRUCTURAL STEEL 0 GAS
❑ REINFORCED CONCRETE ❑ OI 0 OTHER - SPECIFY
❑ MASONRY ( WALL BEARING ) DIMEN IONS !/
0 OTHER - NUMBER OF STORIES TOTAL LAND AREAL '�r \
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS
vy O 0 P IC OR PRIVATE NUMBER OF EXISTIPJG B hIS
INDIVIDUAL ( SEPTIC ) NUMBER OF ED BATHROOM
APPROVED DATE
'''Z'
0 INDIVIDUAL WELL OF EXISTING BATHROOM
oswir
PUD TYPE OF WATER SUPPLY
4 0 PUBLIC ( NAME OF WATER SUPPLY)
( APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY
a
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
0 YES NAME OF ADJACENT WATER BODY
APPROVED DATE BANK HEIGHT SETBACK
PUBLIC WORKS DEPTROAD RIGHT-OF -WAY WIDTH
CQ NAME OF PUBLIC ROAD
NAME of PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED ❑ YES 0 NO
IDENTIFICATION
""
NAME MA I L MAILING ADDRESS ZIP/� TEL NO
OWNER
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CONT .
"-'S'r A 1 E L I C E r1 l E—TV3'-1
ARCH
THE OWNER OF THIS BUILDING AND Tt?E UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
S ATURE OF -P NT AP CATpO T R, 1 PT ER CHA7U BJ OR CASH
92
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APPR• E; , P T ESi ./'
BASE FEE INSPECTION''Q d BLDG SURCHARGE PLAN CHECK
Vii06 3`1 '"�
A � �����"�-_-_-_, ENERGY SURCHARGE $ / ---- TOTAL
JEFyFE��RgSON COUNTY 9 1 1 NUMBER REFUND DATE „II�1TE 1)SS_U
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