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HomeMy WebLinkAboutMLA15-00075 - FPA15-00002 Permit Application¢SON co DEPARTMENT OF COMMUNITY DEVELOPMENT ��L G CISh kL, rI -Inn, 7%%AJ83rh W Id 36-13-9 44 511: n -o( 1,3 -L445 l \t I tt Fdr,xiuPmrnr '/�� PERMIT APPLICATION 0! / Steps in the Permit Process: � '• -Review application checklist to ensure all information is completed prior to submitting application r-..� -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meetwith the Permit Technician by calling 360-379-4450. �7 -This is not a standalone application; it must be accompanied by a project specific supplemental application. -Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only -Building-Permit # PA i S- Oo©02 Related Application#s: MLA# `J— noo7S Site Information . Assessor Tax Parcel Number. Site Address and/or Directions to Property: Access (name of streetIN) from which access will be gained: ✓ Present use of property: a Description of Work (include proposed uses): Wastewater -.Sewage. Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES _ _ NO If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: _Septic Septic Permit#: _ Community Septic Name of System: Case #: Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: Complete _ _ Partial Has a reserve drainfield been designated? yes _ _ No Date of Last Operations & Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: (PZ The authorized agent/representative is the primary contact for all project -related questions and correspondence. The County will mail / e-mail requests and information about the application to the authorized agent/representative and will copy (cc) the owner noted below. The authorized agent/representative is responsible far communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e., County email is not blocked or sent to "f unk mail"). Applicant/Property Owner Information Property Owner: Name: Phone fi: _ RCI 2i9 .SRS% E-mail Address:_ ✓ ' c Please contact Authorized Agent/Re esenta ive with project info.(selectonlyonej. Property Owner Signature: Date: Note: For pumens with multiple owners, attach a separate sheer with ea ner(s) information and signatures. Applicant: Authorized Agent/Representative(if other than owned Name: Address: Phone If: E-mail Address: Professional Is this an Authorized Agent/Representative for: this: project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License fJ Address: Phoneft E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO .YES Engineer Architect _ Surveyor Contractor Consultant Name: License # Address: Phone M E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License If Address: Phone ff: E-mail Address: By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is true and correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in making any issued permit null and void. I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and any required later inspections. Applicant may request notice of the County's intent to n r u o the property for visits related to this application and subsequent permit issuance. Signature: " - Print Name: Date: / (46 as: