HomeMy WebLinkAboutMLA18-00043 Permit ApplicationFfm�3 - c000-�_
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 1 Fax: 360.379.4451
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E-mail: dc,1([f'c , s. c ff( rSe7n. W.i.4ls
PERMIT APPLICATION
Steps in the Permit Process:
-Review application checklist to ensure all information is completed prior to submitting application. CO( jv DCD
-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
Related Application #s:
Building Permit #
MLA#';. " Ct
Site Information
Assessor Tax Parcel Number: 002283032
Site Address and/or Directions to Property: 30 Sunshine !hive. Propp-ly Properlyis accessed from Sunshine Drive Road from
Gardner Beach Road from Diamond Point Road north of I-liqhLway 101
Access (name of street(s)) from which access will be gained: Sunshine Drive
Present use of property: Cleared land with no im rovements
Description of Work (include proposed uses): This permit application is for partial release of property from FPA moratorium
for installation of single family residence and associated utilities
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: Submittal for septic system permit not allowed until release from
X Septic Septic Permit #: moratorium is approved.
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:
Has a reserve drainfield been designated?
Date of Last Operations & Maintenance check:
Complete Partial
Yes No
Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
1 h
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: Catherine Carmella
Address: 112 South 296 Place, Federal Way, WA 9800.3
Phone M (206) 730-7432 E-mail Address: carmella267p__gmail.com
Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature:.LlCG 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:
Address:
Phone #: E-mail Address:
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer X Architect Surveyor Contractor Consultant
Name: Seth Rodman License # 53777
Address: 301 East 6th Street Port Angeles, WA 98362
Phone #: (360) 417-0501 E-mail Address: se
th(a)zenovic.net
Professional: Is this an Authorized Agent/Representative for this project? NO YES
Engineer Architect Surveyor Contractor Consultant X
Name: James laleggio, Wetland Biologist License #
Address: 267 Hudson Street, Port Townsend, WA 98368
Phone M (360) 385-4073 E-mail Address: marine.surveys.inc{cr gmail.com
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 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 I County's intent to Y14
the property for visits related to this application and subsequent permit issuance.
Signature: Print Name::�.�/ Date: /L