Loading...
HomeMy WebLinkAboutPermit ApplicationsDEPARTMENT OF COM868UNI VELOPMENT 621 Sheridan Street, Port lbwnscnd, W. Tcl:360.379.4450 1 Fax: 360.379.4451 Wch: unsnv.cc [.Ic•f fcl5[1r9. W71.d1�:�f�.f�E13» 1i1171tYdL: Vf:1[id3t7lL' 1? -mail: `s iy� Pnn duvP PERMIT APPLICATION eppeft0 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 # N//( Related Application #s: `-)(�Pk� --000 aU MLA )�-A�,C-0 Site Information Assessor Tax Parcel Number: Site Address and/or Directions to Property: a 05$0 4, 977 Access (name of street(s)) from which access will be gained: GJ- rkr( Present use of property: eC� rr Description of Work (include proposed uses): ' ff� J1 on © 1�A1V-, ;- 01,00"I 11, ,u *ice I.'. 'e_' 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 #: Community Septic Name of System: Case #: Are other residences connected to the septic system? Additions or repairs to sewage system: Is it a complete or partial system installation: A I & mplete 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: M,utV_4-- 60cq-T 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 Pmail is nos blocked or sent to "funk mail"). Applicant/Property Owner Information Property Owner: y.�' ^ r Lxio,z Name: L I�IV � r3 - Address: Phone #: � ,'] �, 7 �✓' E-mail Address: I it ;49 Please contact Authorized Agent/Representative with project info. (select only one).dpr'e LX, qv/ •1 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 other than owner) Name: N� i Q Address: 0 X, JU ,Q < t Phone #:S[,— SOLS E-mail Address: cfe ��•* � / � 3c>r ._ !'7VC,) Professional: Is this an Authorized Agent/Representative for this project? NP YES Engineer Architect Surveyor Contractor Consultant Name:-.�rP1��'n5 ICti�6©R!� License# Address: (tri c� Oneijt S72 Phone M —S;)5-7 E-mail Address: Professional: Is this an Authorized Agent/Representative for this project? 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 # 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 an my laws and regulations and I agree to provide access and right of entry to Jefferson County and its employees, representatives rage is for the sole purpose of application review and any required later inspections. Applicant may request notice of th Count s rote o enter upon the property for visits related to this application and subsequent permit issuance. j L/Y7 Signature: Print Name: li► l Lt Date: id, 007 DEPARTMENT OF COMMUNITY 621 Sheridan Street, Port Townsend, WA 98368 Tel: 360.379.4450 1 Uax:360.379.4451 Web: AMY, CO.iCffCrso:t.cva. LIN / C01 Dttulait ev •Io -mail: ic Iff-CNon."yl.a:s OPMENT E W CZ4 DE,C ? 8 ?41a SHORELINE DEVELOPMEI"ZY'NOAI CO T A completed application form is a requirement of submittal. include "N/A" in spaces t MLA #1-7 — 0Mq-1 Case # Application Type (select one): Statement of Exemption- I l Variance* Substantial Development* See Examples on back side I 1 Conditional Use (administrative)* n Conditional Use (discretionary)* of application v 11 1) Does your proposal require in water work and/or works below ordinary high water mark?! No f 2) Does your prop— l requirel�in ,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 ore -application conference is required prior to submitting for a shoreline permit. Site Information Assessor Tax Parcel #:I Name of Body of Water: M r Property Owner Name(s): P A Ste, �e— Project Description Describe the existing property use and condition: Proposed distance from ordinary high water mark to use/development:. feet Describe the proposed work that requires a shoreline permit or permit exemption: eD r a rt� �f VI: � LJ 6 �! �r . 6.....s ' '. aVP.. nu V'. lul 1". talc uvv"u"a n< 'u" Q. ulac me Inrormauon proviaeo nerein, ana in any attachments, is true and correct to the best of his or her knowledge. atrial f seho17 or any omission of a material fact made by the owner/agent with respect to this application packet may result in making a y iss ed per t nul void. r` J Owner Signature: ii Date:P,/-R-77 Print Name: - 0 ) ka k 111 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 administratorls 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 arra compliance with the provisions of this program and Act. A denial of an exempttari 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. Ju1)1�101u'ntil �hnrclio( \[)III101rt( n I'nl,,c '_ of