HomeMy WebLinkAboutBLD1989-00582 0d,DING ERMIT APPLICATION
Jefferson County Building Department P .O . Box 122O urt Townsend. WA 98368
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LOCATJON ( �/
SPECIFIC LOCATION SITE ADDRESS `i7 2/.lA I J 0J
POSTAL DISTRICT , /S1BD IS I ON
LEGAL DESCRIPTION LOT BLOCK DIVISION/ TAX NUMBER
�(, PARCEL NUMBERS O 0// 1 / 4 SECTION
PLANNING AREA SECTION c TOWNSHIP , NORTH RANGEWM
BUILDING INFORMATION
BUILDING TYPE TYPE OF IMPROVEMENTSQUARE FOOTAGE
❑ SINGLE FAMILY PrNEW BUILDING MAIN FLOOR
❑ MOBILE HOME ❑ ADDITION 2ND FLOOR
❑ MODUL,AR HOME ❑ALTERATION BASEMENT
WDETACHED)ATTACHED 0 REPAIR CARPORT
GARAGE_-
0 REPLACEMENT GARAGE /16 2-'
❑ WOODSTOVE 0 WRECKING/DEMOLITION ' COMMERCIAL
❑ MULTI - FAMILY Li RELOCATION/MOVING INDUSTRIAL
NUMBER OF UNITS "----
MOBILE HOMES
❑ COMMERCIAL 0 $3 g
SIZE
❑ INDUSTRIAL YEAR VJ @ $ 16
❑ HOTEL/MOTEL/DORMITORY MAK A @ $8 geQi(O
NUMBER OF UNITS
❑ OTHER - SPECIFY ESTIMATED COST OF 0 a) $8
IMPROVEMENTS TOTAJL, F IR MARKET VALUE
UBC OCCUPANCY GROUP $^ 8/ 7f to $ �1,.,2l
SELECTED CHARACTERISTICS OF BUILDING /
PRINCIPLE TYPE OF FRAME PRINCIPLE TYPE OF HEATING FUEL
WOOD FRAME 0 ELECTRICITY 0 COLLECTIVE SOLAR
` ❑ MANUFACTURED 0 WOODSTOVE 0 PASSIVE SOLAR
«f 0 STRUCTURAL STEEL ❑ GAS ❑ COAL
❑ REINFORCED CONCRETE 0 OIL ❑ OTHER - SPECIFY 4:)N4
❑ MASONRY ( WALL BEARING ) DIMENSIONS .2.4 X litc)
0 OTHER - NUMBER OF STORIES, / TOTAL LAND AREA ,S fie/4',4-
DEPARTMENTAL REVIEW
HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED MDR
�) Onr 0 17PUBL I C OR PRIVATE NVM@ER OF EXISTII DROOMS
i" LW-INDIVIDUAL ( SEPTIC ) NUMBER OF ED BATHROOM
APPROVED DATE M/I'ND I V I DUAL WELL NUI OF EXISTING BATHROOM
V""r; PUD TYPE OF WATER SUPPLY
❑/PUBLIC ( NAME OF WATER SUPPLY)
cAPPROVED DATE U PRIVATE ( NAME OF WATER SUPPLY mat*,
--
PLANNING DEPT . WITHIN SHORELINE JURISDICTION
❑ YES NAME OF ADJACENT WATER BODY
-rd
[r NO
APPROVED DATE BANK HEIGHT SETBACK
�(\\) PUBLIC WORKS DEPT ROAD RIGHT-OF -WAY WIDTH
NAME OF PUBLIC ROAD 77'!/1 45 j
NAME OF PRIVATE ROAD
APPROVED DATE ROAD ACCESS PERMIT REQUIRED 0 YES (lNO
IDENTIFICATION
NAME I MAILING ADDRESS I ZIP ITEL NO
OWNER 1�
ir17 E Erz `L- 1• 34=3' 11s E. /3/ 57-S77 7?-
Yi.q ducc,iivAlt. diAii9, PE3lo ra, / Z_
CONT de f i s • ,..1. e Al 1�(t Lam/ e 1(2 / �' b✓�KJ
PA I E "'Ll [ E NSE NO ,
• RCH
'7 Lk/"1 r t-Je%-rrreY a77r, _ l .'-'fir
HE OWNER OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS.
IGNA URE OF APPLICANT
APPLICATION DATE I RECE I PTT NUMBEC�j CHECK F/{VMBEOR CASH
.0 .dL,....4..)C.4 � Z�.-6,//. 1/ -y4,L--! +--6 1 I 0 ` l AP- -OED BY PERMIT FEES
11, 0 D BASE FEE INSPECTION
A ' ...1,
„ - � ...v i r 5 BLDG SURCHARGE PLAN CHECK
9 ' ► 1`11111111,,... ENERGY SURCHARGE D
tit? I'1/r TOTAL
JEFFEIi&o,V calm. _
PIAr011 4 106 aFp? 10 9 1 1 NUMBER t REFUND DATE `DA�T= u
li BUILDING OFFICIAL I
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JEFFERSON COUNTY
PLANNING&BLOG OW