HomeMy WebLinkAboutPremit Applicationw�SON cO0 DEPARTMENT OF COMMUNITY DEVELOPMENT
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PERMIT APPLICATI 1111(
Steps in the Permit Process: L--. "OL" lWyEAT
-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 Emildixg Permit # SO r8l (o — 000 21
Related Applicton#MLA #1(0—Od0FS.S
Site Information
Assessor Tax Parcel Number: 0 o
Site Address and/or Directions to Property: C7RK F,j 1�-.
FbeT F1aiLoG,l,[- wfr 40 3
Access (name of street(s)) from which access will be gained: mat< gAI( e<� knd- R. wVrdtbOv)
TV u In ORK W 5
Present use of property: M S t- * Acl0
Description of Work(include proposed uses): rT V(3 -t -H )Z,% &- S• Wi- 2 Ste, LVS
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#: 5SP43-0031f6
CommunitySeptic Name of System:
+ SEP —qrc „h0o
Case#:
_
Are other residences connected to the septic system?
Additions or repairs to sewage system:
Is it a complete or partial system installation: Complete
Has a reserve drainfield been designated? Yes
Dateof Last Operations& Maintenance check: 3Un2 zollo
_Partial
NVA
Attach last report to application
Describe or attach any drainfeld easements, covenants or notices on title, which
may impact the property:
Tho authorized agent/reprrsentgiw 11 lh> r—ry rin>art for all nmiert-cFlared gn,sron, and rnr.rcpnodrnr-' The Counry will mail
/ e-mail requests and information abont the application to the introit, 1,,ut/1epresentation and colli Copy (11) he owner noted
below. The authorizer) agent/representative is responsible for communicating the information to all parties involved with the
application. It is the responsibility of the authorized agem/representative and owner to ensure their mailbox accepts Countv email li c,
rounim am-iI :c ont hlnckad or sent to"iunkn iWj.
Applicant/ Property Owner Information_
Property Owner:
Name: j'av;- % VInA Skcc6;zn
) Address: I al 9`7 _'t, >7ni l.(u 4 L.00iiA r. D6- " R IC
Phone #:_ u�5- 1 141 E-mail Address:
r, Please contact Authorized Agent/Representative with proiect info. (sclect only one).
Pro^erty owner Slgnatuoe J./�-�.p��) Date:
Note: For protects with muitlPle oi attach a separate sheet with each ownerlsi information and signatures.
Applicant: Authorized Agent/Representative(Ifomerthaoowner)
nlomo-—
Addlese: rrV &Doc F41 _ _o=r '�ouJn•se f�LKi:_< 463io0 __ __.
Phone M: 3(o0 130(') 63 -E-mail Address: .{+,y@Ji 6( pyl-i
r
Professional: Is this an Authorized Agent(Representative for this project? NO YESx�
Engineer Architect Surveyor Contractor ycon_tact
Name: License A
Address
Phone 6: E-mail Address: j
IProfessionaC Is this an Authorized_Agent/Representative for this proieR7_. NO YES
Engineer :architect Survevor Contractor Consultant
i
Name: License it
Address:
Phone #: E-mail Address:
1 Professional: Isthis an Authorized. Agent/Representative for this project? -NO-'-- --'-Y
Reg ger Architect Surveyor Contractor
Consultant
Name: -- _._ _. _. License#
Address:
Phone N: E-mail Address ii_ I,p•lY
r
correct ro he best of his or her knowledgeAny material falsehood or an pulsion 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,
ln,net agree to that all zcibiilas I intend n, undertake o nmplete assnr hod with this purnii will be performed in compliance 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 fpr visits related to this aapp-plication and subsequent permit issuance.
Signature. runt Name: �ru� d eo�SP� Date. 1.0 y41b