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Home My WebLink AboutMLA16-00036 Permit Applicationw4SON co DEPARTMENT OF COMMUN }��/VEI oPMENT 621 Sheridan Street, Pntt'Pownsard, WA 98368 "f'e1:3603]9A45p lax: 360.379,4451"�—i, Web: _r_j =fit/ .,� qt, 9SxIN0�0 JEFF R PERMIT APPLICATION F%?SpycOUN Steps in the Permit Process: rY0C1) -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; H 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 DepartmentUse Onty Building Permit p Related Application Ns' MLAk site Information Assessor Tax Parcel Number: 996400001, 996400007, s 996400008 Site Address and/or Directions to Property: 1060 WhitneyRd Quilcene WA 98376 Access(name of street(s)) from which access will be gained: Whitney Rd off of Coyle Rd Present use of property: Residential Description of Work (include proposed uses): Residential wastewater -Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served q sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: x Septic Septic PermitM SEP72-00042 Community Septic Name of System: Case t Are other residences connected to the septic system? No Additions or repairs to sewage system: Is it a complete or partial system installation: Complete x Partial Has a reserve drainfield been designated? Yes No Date of Last Operations & Maintenance check: Attach last report to application Describe or attach any drainfieid easements, covenants or notices on title, which may impact the property: 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., iIit blocked or sent to :junk mail'. Coun emas no Applicant/PrOPertif Owner Information Property Owner: Name: Seaman ventures, LLC C/O David W. Whitney Address: 9817 Mona Lisa LN Bakersville CA 93312 Phone #: (206)406-8084 E-mail Address: dwwhitnev@hotmail.com Please contact Authorized t/Rep ntative with project info. (select only one). Property Ow er Signature: Note: F. ro ects with oulopl. ers, attach a separnesSeet.1theadh owners) Inf xmanon and sipatwis Applicant: Authorized Agem/Re resentative(uouvrthan owner) Name: Northwestern Territories Inc. Address: 717 Peabody Port Angeles WA 98362 Phone#: (360)459-8441 E-mail Address: Professional: Is this an Authorized Agent/Representative for thisproject? NO YES X Engineer Architect Surveyor X Contractor Consultant Name: Kent L. Robinson License# 19583 Address: 717 Peabody Port Angeles WA 98362 Phone If: (360)452-8491 E-mail Address: kentRnti4u.com Professional: Is this an Authorized Agent/Representative for thisproject? NO YES Engineer Architect Surveyor Contractor Consultant Name: License # Address: Phone #: 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 #: 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 corn pliance with all applicable federal, state and county laws and regulations and 1 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 enter upon the property for visits related to this application and subsequent permit issuance. Signature: , ',' l/. Print Name: e�vri 11 c,///i ki Date: /� i� gSON cp DEPARTMENT OF COMMUN DEVELOPMENT 44w G.4 621 Shimutan Stmt. Pon 1'ownsrnJ, W.19a348 % Tf 1, 360.379.4450 1 Fav 360.379.4451 , I/✓ 1+.-mtil: Jul g�;54ri—�5 �j� y,1 Wb: ,j/e� APR PERMIT APPLICATION 'Q% ONCOIJ, .:ops in me Permit Process: ry -Review application checklist to ensure all information is wmpleted prior to submitting application. OL,O -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 360-379-445u. -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 Related Application Building Permit # Site Information Assessor Tax Parcel Number: 996400003, Site Address and/or Directions to Property: 0 996400004, 996400005, 996400010, & 996400011 WhitneyRd uilcene WA 98376 Access of street(s)) from which access will be gained: Whitney Rd off of Coyle Rd Present use of property: Residential Description of Work(include proposed uses): Residential Wastewater -sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: Septic Septic Permit#: SEP -000 Community Septic Name of System: Case#: Are other residences connected to the septic system? No 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: is the primary contact for all project -related questions and correspondence. The County will mail mt the application to the authorized agent/representative and will copy (cc) the owner noted mtative is responsible for communicating the information to all parties involved with the It is the responsibility of the authorized agent/representative aild owner to ensure their mailbox accepts County email (i.e., then email rs nuc U—m o �....... _.... _._. . Applicant/Property Owner Information Property Owner: Name: Sohn Whitney Address: 2744 Lariat LN Wallnut Creek CA 94596 Phone#: (925)933-8943 E-mail Address: lack whitne hotmail.com Please c tact Authorized Agent/Representative with project info. (select only one). k� ,`•� Date: 4•a-L� 2p� Property Owner Signature: Note: ror P oje,, with mul ple owner, attach a si, arate sheet with each cwneds) information and signatures Applicant: Authorized Agem/Representative(amharthanowrerl Name: Northwestern Territories Inc. Address: 717 Peabody Port Angeles WA 98362 Phone#: z�nt asp-R4gt E-mail Address: professional: Is this an Authorized Agent/Representative for this project? NO YES X Engineer Architect Surveyor X Contractor Consultant Name: Kent L. Robinson License# 19583 Address: 717 Peabody Port Angeles WA 98362 Phone#: (360)452-8491 E-mail Address: kent@nti4u.com : Is this an Authorized Agent/Representative for this project? NO YES Architect Surveyor Contractor Consultant License # =this E-mail Address: l: Isthis an Authorized Agent/Representative for this project? NO YES Architect Surveyor Contractor Consultant Name: License # Address: Phone #: 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 respectto 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 enter upon the property for visits related to this application and subsequent permit issuance. Signature:. F- Print Name:��`N �•� �a Date; ID'11—zas 4.S�N cO DEPARTMENT OF COMMUNI EVELOPMENT tCw �•� 621 Sheridan Saeeq Pon'Pow.,,,d, W.4 98368 ,yc1:360.3]9i4501fax:360.3794451 ,�,�tr'�ry Web: jff r/ 1 �•L I�rmaiLd d(u� -ff 'b+�� 9'sHING�O� APR PERMIT APPLICATION ✓Er•FFRS�N 2016 Steps in the Permit Process: cOUr'' -Review application checklist to ensure all information is completed prior to submitting application. �C(3 -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 # Related Applicata ifs• MlA# site Information Assessor Tax Parcel Number: 601 342 019 She Address and/or Directions to Property: 931 WhitneV Rd Ouilcene WA 98376 Access (name of street(s)) from which access will be gained: Whitney Rd off of Coyle Rd Present use of property: Residential Description of Work (include proposed uses(: Residential wastewater -sew Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served by sewer identified above, identify t pe of se is system below: Type of Sewage System Serving Property: X Septic Septic Permit #: SEP80-00092 Community Septic Name of System: Case #: _ Are other residences connected to the septic system? No Additions or repairs to sewage system: Is it a complete or partial system installation: Complete X 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: is the primary contact for all project -related questions and correspondence. The County will mall rut the application to the authorized agent/representative: and will copy (m) the owner noted mtative is responsible for communicating the Information to all parties involved with the the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e., ..L —H-1 many erndn o—.-.,....-... -......._ _.....__- Applicant/Property Owner information Property Owner: Name: John Nelson Address: P.O. Box 369 Trout Lake, WA 96650 Phone If: (509)395-2889 E-mail Address: jeeva@embaramail.com 1/ Please contact Aut 'zed t/Re entative with project info. (select only one). --r— property OwnerS'nature: — Date: Co Note: For projects,vith multi leo ers, amdi a separate sheet with each ovmerfs) information and signatures. Agent/RePreseMative (uomertnan owMrl orthwes717 South Peabody Port Angeles WA 98362 rthorized 3601459-9491 E-mail Address: Is this an Authorized ent/Represfor project? NO YES X Architect Surveyor X Contractor Consultant ent L. Robinson License If 19583 Address: 717 South Peabody Port Angeles WA 98362 Phone#: (360)452-8491 E-mail Address: kentlanti4u.com professional: Is this an Aut=AgenttRepresentative for this project? NO YES Engineer Architect Contractor Consultant Name: License # Address:Phone #: E-mail Address: Irrofessional: Is this an Autntative forthis project? NO YES Engineer Architect Surveyor Contractor Consultant Name: License # Address: Phone #: 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 ent r upon the pro erty for visits srrelated to this application and subsequent perm; issuance. Signature: Print Name: rJo91/ Dater DEPARTMENT OF COMM 7D1�VE LOPMENT ¢� G i ,d. rr,.0 r rn3-9uu I no. da ,� //// Lam. �SKf n�� ✓FF��R ! 2p�, PERMIT APPLICATIONs�NCOUN steps in the Permit Process: ryDOD -Review application checklistto ensure all information is completed priorto 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 # Related Application #s' MLA If Site Information Assessor Tax Parcel Number: 996400002, 996400006 & 996400009 Site Address and/or Directions to Property: 1341 WhitneyRd uilcene WA 98376 Access(nameof street(s)) from which access will be gained: Whitney Rd off of Coyle Rd Present use of property: Residential Description of Work(include proposed uses): Residential Wastewater - Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer system? YES NO X If not served by sewer identified above, identify type of septic system below: Type of Sewage System Serving Property: X Septic Septic Permit#: SEF70-00037 Community Septic Name of System: Case#: Are other residences connected to the septic system? No Additions or repairs to sewage system: Is it a complete or partial system installation: Complete X 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: 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., Is not olocxep or sem .� uroperty Owner Informationwner:Mary Ann Whitney—Hall 1240 Swiftshore Circle, West Linn, OR 97068 Mapz- (503)334-7965 E-mail Address: mwhitne —ha11@comcast.net Please contact Authorized Agent/Representative with project info. (select only one).wner (,(,�p Date: Lf'_' Signature: Note: For projects with multi le owners, att h.s,,p.,ou, sheet with howner(sl in formation and signatures. Note: Applicant: Authorized Agent/Representative (if other than owner) Name: Northwestern Territories, Inc. Address: 717 Peabody Port Angeles WA 98362 Phone#: un) a59—nagt E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? NO YES X Engineer Architect Surveyor X Contractor Consultant Name: Kent L. Robinson License It 19583 Address: 717 Peabody Port Angeles WA 98362 Phone#: (360)452-8491 E-mail Address: kent@nti4u.com Isthis an Authorized Agent/Representative forthis project? NO YES Architect Surveyor Contractor Consultant License # =1,this: E-mail Address: l: Is this an Authorized Agent/Representative for this project? NO YES Architect Surveyor Contractor Consultant Name: License # Address: Phone #: 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 C e COUin/ w to fer upon the property for visits related to this application and subsequent permit issuance. Signature: 1 Print Name��U� Date: V