HomeMy WebLinkAboutMLA16-00029-FPA16-00002 Jablonski Permit Applicationt
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 SheridanSneer,PottTowoamd,WA 98368
Td: 360.379.44501 F.i 360.379.451+Web:dcX ,t 1 .AE -mail: dcd(¢?co'effenon wa u, iV tL.]' 72_00' 1 f U —00D 10
PERMIT APPLICATION(— p p
Steps In the Permit Process: IIU�I
-Review application checklist to ensure all information is completed prior to submitting applic in.
-Make sure septic has been applied for and water availability has been proven. SAAR 2 4 2N
-Make an appointment to meet with the Permit Technician by calling 360-379-4450. :J LI�
-This is not a standalone application; it must be accompanied by a project specific suppt�remel ay�'"It :;,Jtt
-Fees will be collected at intake. Additional fees may apply after review and payment is rt uiralft9f0ire P"MiCis fssl
For Department Use Only Building Permit #
Related Application #s: MLA #
Site Information
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Assessor Tax Parcel Number: '9-2/.3
330 ( 8'
Site Address and/or Directions to Property:
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Access (nay a of street(s)) from which a}ess will be gained:
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Septic Septic Permit#:
Present use of property: IvolvE
Community Septic Name of System:
Description of Work (include proposed uses):
Are other residences connected to the septic system? 410
e
Additions or repairs to sewage system: (f
wastewater - Sewage Disposal
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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:
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Type ?!fSewage System Serving Property:
Septic Septic Permit#:
Community Septic Name of System:
Case#:
Are other residences connected to the septic system? 410
Additions or repairs to sewage system: (f
Is it a complete or partial system installation: Complete
Partial
Has a reserve drainfield been designated? Yes
No
Date of Last Operations & Maintenance check: A /,'
Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, whisk
may im act the property:
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`17* Case i"JOT
70"1 C&%o
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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 for 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 stint to 'it nk mai Pl
Applicant/Property Owner Information
-
Property Owner:
Name:
Address:
Phone #: E-mail Address:
Please contact Authorized Agent/Representative with project info.
Prope w er Signature:
Note: For projects welt multiple owners, attach a separete sheet with each owneds) information and signatures.
(select only one).
Date:
Applicant: Authorized Agent/Representative(if other than owned
Name:
Address:
Phone #:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this project?
NO YES
Engineer
Name:
Address:
Architect Surveyor Contractor
License #
Consultant
Phone #:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this project?
NO YES
Engineer
Name:
Address:
Architect Surveyor Contractor
License #
Consultant
Phone #:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this project?
NO YES
Engineer
Name:
Address:
Phone #:
Architect Surveyor Contractor
License #
E-mail Address:
Consultant
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, represeatives or agAnts for the sole purpose of application review and any required later inspections. Applicant may
rest n tic un ,t to enter upon the property for visits related to this application and subsequent permit'suan e.
Signat f Print Name: hl �/ ABt,orJsk( �fi_Date:
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