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Home My WebLink AboutPermit ApplicationsDEPARTMENT OF COPUMUNliTY DEVELOPMENT 621 Sheridan Street, Port Townsend, WA 98368 Tch 360.379.4450 1 Fax; 360.379.44.51 Web: www. vi LaraaiI: dcd o of PR PENT APPILICATION 4'-'rFF1RS0N c®U Steps in the Permit Process: N , OCO -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 360-379-44S0. -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 #s: snPi<,5 - CcNcxn.5 Site information Assessor Ta'Parcel Number: l Site Address and/or Directions to Property: Access (name of street(s)) from which access will be gained: Present use of property: Description of Work (include proposed uses): //)/,;, T")"-, 7► Building Permit, # MLA # i X - ("i G Le- 9t�±P iL4 c.. / �riii T A Wastewater - Sewag+e 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: Y Septic Septic Permit #: ��.(_ C Community Septic Name of System: (-n -6 . y .ems 6,r6 V- Case #: Are other residences connected to the septic system? q�7U Additions or repairs to sewage system: Is it a complete or partial system installation: Complete ')G Partial Has a reserve drainfield been designated? Yes No Bate of Last Operations & Maintenance check: Attach last report to �� application Describe or attach any drainfield easements, covenants or notices o title, which may impact the property: Permit Application PagL 1 of 2 The authorized agent/representath, the primary contact for all project -related queboons 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 Informatlon 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., Coun email is not blocked or sent to `junk mail"I. Owner Information Property Owner: Name: le Address: 2 Phone #: r s E-mail Address: Please contact AU�Iorizecl Agent/Representative with project Property Owner Signature: Note: For prolects with multinlp. n, U_'M Name: Address: Phone #: attach a separate sheet with each Professional: Is this an Authorizedgent/Rel Engineer Architect ✓ Surveyor JC than 5wner(s) Information and s ner) E-mail Address: ltative for this prolec Contractor nvame. LL�L�-1 Ir y iY License # Address: Phone #: ...,.r�r 35-? 1 CM2. _ E-mail Address: Professional: Is this an AuthorizedAgent/Representative for this pr9ject Engineer Architect Surveyor Contractor Name: �L ,, lcli ,: License # Address: Phone M E-mail Address: ProfessIonh Is this an Authorized ent/Re resentative for this ro'ecl Engineer Architect Surveyor Contractor Name: ; RK Z D License # Address: to01 ks CLV3G? Phone #: - 3,%S' - C.1 y V E-mail Address: (select only one). Date: NO YES Consultant NO YES Consultant NO YES Consultant a 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 Co ; ty's int nt to enter upon the property for visits related to this application and subsequent permit issuance. Signature; Print Name: Date: L Pcmtit Application Page 2 of 2 DEPARTMENT OF COMMUNITY DEEVEL r1T'TS: 631 Sheridan Street, Port'fowusend, WA 98368 Tel: 360.379.4450 1 Uax:360.379.4451 Web: wtiva.r'ir.icFfcnTrn.�vr.ir�camnirmiC� cvsl❑ mc. x: e^��?ry g� 1 r -mail: �ieciCyt c^.icFFenrrst.tya.u+ I t lec?`y� ICATION 0� �f) SUPPLEMENTAL LINE DEVELOPMENT �� A completed application form is a requirement of submittal. Include "N/A" in spaces that do not apply. MLA # I g_ bdaZ2 Case # ISS -C�GC �S Application Type (select one): Statement of Exemption- I l Variance* ❑ Substantial Development* See Examples on back side I 1 of application Conditional Use (administrative)* [ Conditional Use (discretionary) 1) Does your proposal require in water work and/or works below ordinary high water mark? Yes [ ] No [ 2) Does your pronncal require 1 x,000 sq/ft or more of impervious surface and/or non -single family structures of 5,000 sq/ft or more? Yes [ ] No [ ] * If either of the boxes for 1 or 2 above are checked yes or if the permit type above has an asterisk then a pre -application conference is re uired prior to submitting for a shoreline permit. Site Information Assessor Tax Parcel #: Name of Body of Water: ?01 S210/9 Describe the proposed work that requires a shoreline permit or permit exemption: Property Owner Name(s): dos � Sku.Y 6,n/ Her Project Description Describe the existing property use and condition: Proposed distance from ordinary high watermark to use/development: 23' feet Describe the proposed work that requires a shoreline permit or permit exemption: rr - 71-6 o 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 m tenial falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in making any i ed permit p0119 id. Owner Signature: �4 Date: �✓ Print Name: 0�6 z!' HC -7 These activities require a formal statement of Exemption issued by Jefferson County. Check 'Statement of Exemption' box on the front of this form and submit with Permit Application to apply for your Exemption Approval. 18.25.570 Statement of Exemptions (1) The administrator is hereby authorized to grant or deny requests for statements of exemption from the shoreline substantial development permit requirement for uses and developments within shorelines that are specifically listed above. Such statements shall be applied for on forms provided by the administrator. The statement shall be in writing and shall indicate the specific exemption of this program that is being applied to the development, and shall provide a summary of the administrator's analysis of the consistency of the project with this program and the Act. As appropriate, such statements of exemptions shall contain conditions and/or mitigating measures of approval to achieve consistency and compliance with the provisions of this program and Act. A denial of an exemption shall be In writing and shall identify the reason(s) for the denial. The administrator's actions on the issuance of a statement of exemption or a denial are subject to appeal pursuant to the appeal provisions in Article X of this chapter. 18.25.560 Exemptions listed — This is a summary from JCC18.25.560, please review the code section for detailed information regarding these exemptions. (1) Fair Market Value. (2) Maintenance and Repair. (3) Residential Bulkhead. (4) Emergency Construction. (5) Agriculture. (6) Drainage. (7) Navigation Aids. (8) Single -Family Residences. (9) Residential Docks. (10) Irrigation. (11) State Property. (12) Energy Facilities. (13) Site Exploration. (14) Noxious Weeds. (15) Watershed Restoration. (16) "Watershed restoration project" (17) "Watershed restoration plan" (18) A public or private project, the primary purpose of which is to improve fish or wildlife habitat or fish passage. DEPARTMENT OF COMMUNITY DEVELOPMENT: 621 Sheridan Street, Port Townsend, WA 98368 Tel: 360.379.4450 1 Fax: 360.379.4451 Web: www.co,jeffersoaama.uB/cornmunitdCv nnmcnt a 4+ , E-mail: dcd o,jeffcrson.wa,uv�rr Oct) P M� RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt #: Date: Related Application #s: SSS' r �s — � 'r I -A I S- (Uo0Zis Payment #: Site Information Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office use) Owner Name: 'D -Au 1130?) Assessor Tax Parcel #: -70132 4911 Type of Building Additional Floors - heated / unheated New Replacement_ Relocated_ Addition ^ _ Repair` Demolition Detached Garage - heated / unheated o *A separate permit is required Select One: Single Family Residence Modular_ _ Other list Proposed Building/Project _ Number of floors # new bedrooms j existing - total bed # new bathrooms^ ixisting 'J� total bath Heat Source era RX Select all that apply: Electric Heating Oil Wood Propane Enter the square footage (sq/ft) that applies in each field: Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office use) Residential/ Commercial Main Floor 1130?) Residential / Commercial Second Floor Additional Floors - heated / unheated Basement - unfinished b Li Basement - finished space or habitable "' Detached Garage - heated / unheated o Attached Garage - heated / unheated Garage 2nd fl - unfinished storage Garage 2nd fl - finished space or habitable 00 Carport - 2 walls or less Deck - uncovered _ Covered porch (, Other (shed, barn, pole bidg,etc.) Estimated Cost of Project (Required): $ $ Supplemcncal SIS R I List existing buildings on property (i.e. house, earaae, accessory dwelline unit. shed. harn. mobile home. otherl: All Existing Buildings on Property Use r rami �i��h 4r if J4411d S� Builders Statement The signer of this statement certifies that they are the Owners of the parcel referenced herein, that they are not licensed contractorsand that t y will be assuming the responsibility of the General Contractor for the proposed project. Signature: 'ii& Print Name: 0AW 6Ar4,'- 5 Date: 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 app ' tion packet may result in making any issued permit null and void. Signature; ,. Print Name: l2wil %-Tclo i Date: For Department Ute Q_nl ` Building Permit Fees Building Base Plan Check Review Land Use Review Septic Review Potable Water Technology/Scan State Fee Other Fees Shoreline Exemption Zoning Zoning Other New Address Total Fees Receipt # Date: Cash/Check/CC: 5upplrmelm"I tip+R 2 $134.00 $134.00 $23.00 $4.50