HomeMy WebLinkAboutBLD1989-00573 (3U DING 'ERMIT AP} ' A-ION gm
Jefferson County Building Departrnent'P .O . Box 1220.117t To`wnsenA . WA 98368
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LOCAT I OIL
SPECIFIC LOCATION SITE ADDRESS 7� / //
POSTAL DISTRICT 'f /SUBDIVISION ,
LEGAL DESCRIPTION LOT BLOCK / DDIVISION TAX NUMBER 4�.�.-
d7 PARCEL NUMBER' an/ ! 0.15 1 / 4 SECTION
PLANNING AREA (7-- SECTION TOWNSHIP �;i NORTH RANGE I , ?a'C WM
BUILDING INFORMATION
BUILDING TYPE TYP OF IMPROVEMENT SQUARE FOOTAGE
❑ SINGLE FAMILY NEW BUILDING MAIN FLOOR
❑ MOBILE HOME U 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
MOBILE HOMES
❑ COMMERCIAL (V) @($3 I '
SIZE
❑ INDUSTRIAL YEAR 0 @ $ 16
❑ HOTEL/MOTEL/DORMITORY 1
MAKE , - L 1' 4 a@ $ .:). `.. '1 !
�('� UMBER OF UNITS
t � 1 Q�p(OTHE - SPECIFY ESTIMATED COST OF 0 a@ $8 I
�" 'J J • :,.� IMPROVEMENTS TOTAL FAIR MARKET VALUE
�i- UBC OC � CYOGR P $ $ - } CJIC
SELECTED CHARACT ISTIC/OS "SF BUILDING
PRI CIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
WOOD FRAME ❑ ELECTRICITY ❑ COLLECTIVE SOLAR
❑ MANUFACTURED ❑ WQODSTOVE 0 PASSIVE SOLAR
❑ STRUCTURAL STEEL 'Er—GAS ❑ COAL
❑ REINFORCED CONCRETE ❑ OIL ❑ OTHER - SPECIFY q,
❑ MASONRY ( WALL BEARING ) , DIMENSIONS 71- y 0 /�
❑ OTHER - NUMBER OF STORIES 2. TOTAL LAND AREA ]) IL)
..! DEPARTMENTAL REVIEW
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L. HEALTH DEPARTMENT J TYPE OF SEWAGE DISPOSAL t NUMBER OF PROPOSED REDROOMq mod 1, �
p ❑ PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS 4�
f ( ,j 3// /v ay'i ND I V I DUAL ( SEPT I C ) NUMBER OF PROPOSED BATI FZOOM
APPROVED DATE
❑ I ND I V I DUAL WELL NUMBER OF EXISTING BATHROOM
PUD TYPE OF WATER SUPPLY
❑ P LIC ' ( NAME OF WATER SUPPLY)
APPROVED DATE PRIVATE ( NAME OF WATER SUPPLY
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
(VNO
APPROVED DATE BANK HEIGHT SETBACK
PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
`a NAME OF PUBLIC ROAD
� „ NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED ❑ YES ❑ NO
IDENTIFICATION
NAME MAILING ADDRESS ZIP TEL NO
O W N E R - J. -2//`) //' ) �.. dec3S
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CONT J20-ef--- 4
-STATE LircruSE NO
ARCH
THE NER OF HIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
l G UR (C/F APPL IICAT III O�)hyL�(iJ]ATE RECEIPT
J}N
UMBER CHECK JN/�UM JEER OR CASH
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, . A — -
PIPIt 9 PERMIT FEES
^C2 (D}--BASE FEE INSPECTION
M� 1 8 C��jJ 6� BLDG SURCHARGE PLAN CHECK
. 1FERSOX 01.113TY I51,
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J�& ENERGY SURCHARGE Y c 5�
P TOTAL
911 NUMBER REFUND DATE DAT IS
BUILDING OFFICIAL — /
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APPROVED
MAR 15 u t L.Q �kk‘Me CS\ .
cERSUN COUNTY
Pt31NNING&8LD6 DEPT
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