HomeMy WebLinkAboutMLA16-00027 Permit Applicationb__ I (,e-cct�
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PERMIT APPLICATION
Steps in the Permit Process:
-Review application checklist to ensure all information is completed prior to submitting application.
-Make sure septic has been applied for and water availability has been proven.
-Make an appointment to meet with the Permit Technician by calling 360-379-4450.
-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 # 11Q —O[7� 1
Related Application its: MLAN 1(..-t�FXI'S/�SPP�Io-�DO ((5
site Information
Assessor 7az Parcel Number: O O
Site Address and/or Directions to Property: .i i A
N
Access (name of street(s)) from which access will be gained:
Present use of property: 42 Q
Descrip . of Work (include proposed u{es):
GMC U
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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#: C -Z f, �(3T—
Community Septic Name of System: 00r),er,6 rvr( -fy,,AJ\ Case& -C'pl4
Are other residences connected to the septic system? _'I/�_
Additions or repairs to sewage system: _ A 0
Is it a complete or partial system installation: Complete_._ Partial
Has a reserve drainfield been designated? Yes _ No
Date of Last Operations& Maintenance check: /0 -/r{ -/I Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
P2�,1�+-poo25
The authorized agent/representative is the primary contact for all project -related que ��f000yyys ce_Shg,4ounly will mail
/e -mall requests and information about the application to the authorized agent/repr spp{jt 1(o-3,jl(� d
below. The authorized agent/representative is responsible for communicating the lnfor a v
application. It is the responsibility of the authorized agent/representative and ownertb re their mai ox ace [ it (i.e.,
C ailisnor blocked or sent to "junk mail").
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Applicant/Property Owner Information-
PropertyOwner:
Name: IGMC.n
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Address:
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Phone #:f19
302,.-I q E-mail Ad
Please contact Agent/Representative with project info.(select on
one).
�Authorized
Property Ovine__Sig t rerr�lww ina,A.�� �n�fRy�,/ ����a•L-Date—:
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No�e: For proiPt[swith maniple owners auachaseparatesheet with eacM1 awnerlsl information and si awns.
A pliwnt: Authorized Agent/Reeresentative(rtotherthanowned
Name:
Address:
Phone 0:
E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this project? NO
YES
Engineer
Architect Surveyor Contractor _
Consultant
Name: VV
r license#
Address:
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Phone#: '('a
.k l.d C%&,2) 4S'•Af31E-mail Address:
Professional:
Is this an Authorized Agent/Representative for this project? NO
YES
Engineer
Architect Surveyor Contractor X" c
`"___-._
Consultant
Name:
UnILIB firt(A(i License#
—'-
Address:
CSOX /1 �f la UI�LB./jjL Wil 903376
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Phone# ;']
_ E-mail Address: ---
Professional:
Professional:
Is this an Authorized Agent/Representative forthis project? NO
YES
Engineer
Architect _A Surveyor Contractor
Consultant
Name:J 2rry
Q r C� Q r e License If
Address:
brss>� .moi --..as, Sy w'1483-$
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Phone#:z/.nl
.3 /_ 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 pmasion 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 Cm s intent to enter upon the property for visits related to this application and subsequent permit issuance.
Signature: P-tName:G%rr:frne.A.CidrLDate: 12 :2g-/5