HomeMy WebLinkAboutMLA17-00064 permit applicationDEPARTMENT OF COMMUN DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 1 Fax: 360.379.4451
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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 #
Related Application #s: MLA #
Site Information
Assessor Tax Parcel Number: 502291005
Site Address and/or Directions to Property: -11940.3 Highway 101, Brinnon WA 98190
Access (name of street(s)) from which access will be gained:
From Highway 101 onto an existing paved, private easement access road
Present use of property: Vacant Land
Description of Work (include proposed uses)' I proposal Is development of a single-family, two-bedroom residence (-2072 sq.ft. Main Area/ 670 sq.ft. Garage/ 1012 sq.ft
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visitor parking / turnaround area. The proposed residence will be connected to an existing two bedroom septic system on the site
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:
TypeofSewage System Serving Property:
V Septic Septic Permit #: SEP94-00461
Community Septic Name of System: Parcel 502291005 Case #: SEP94-00461
Are other residences connected to the septic system? No
Additions or repairs to sewage system: None
Is it a complete or partial system installation: Complete / Partial
Has a reserve drainfield been designated? Yes No
Date of Last Operations & Maintenance check: 10/16/2015 Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
None
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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 sent to "junk mail").
Applicant/Property Owner Information
Property Owner:
Name: Steven P. and Marilyn F. Barnowe-Mever
Address: 214 Pleasant Valley Road, Winlock, WA 98586
Phone #: (360) 880-0689 E-mail Address: nighthawktf@hotmail.com
Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature: Date:
Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and signatures.
Applicant: Authorized Agent/Representative (if otherthan owner)
Name:
Address: _
Phone #: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant
Name: Tim Talbott (TK design I build) License #
Address: 250 Rhododendron Lane, Brinnon, WA 98320
Phone #: (425) 818-0954 E-mail Address: TKdesignbuild@gmail.com
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer �� Architect Surveyor Contractor Consultant
Name: Michael S. Deeney (Creative Design Solutions, Inc.) License # 5100110
Address: Post Office Box 2787, Port Angeles, WA 98362
Phone #: 360 457-6353 E-mail Address: mike@cds4you.com
Professional: Is this an Authorized Agent/Representative for this project? NO _ YES
Engineer Architect Surveyor Contractor Consultant
Name: Dan McShane (Stratum Group) License # Licensed Engineering Geologist
Address: PO Box 2546 Bellingham, Washington 98227
Phone #: (360) 714-9409 E-mail Address: mcshanedan@gmail.com
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 enter upon the property for visits related to this application and subsequent permit issuance.
Signature: i Print Name: Steven P. Bamowe-Meyer Date: 1017/17
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