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Home My WebLink AboutNOA - Application FormDEPARTMENT OF COMMUNITY DE\IELOPMENT 621 Sheddan Street, Port Townsend, WA 98368 T* 360.379.4450 | Fax 36(t.379.445t Web: www.co.ieffenon.wa.us /communitvdeveloprrnent E-mail dcd@co.iefferson.wa.us D Ii'tI, liUL\ trGtr[VIE PERMIT APPLICATION l,tAR I 4 2018 Steps in the Permlt Process: -Review application checklist to ensure all information is completed prior to submitting -Make sure septic has been applied for and water availability has been proven. -Make an appointment to meet with the Permit Technician by calling 350-3794450. applicatibn.' JEttERS0N C0trNlY 0f -Thls ls not a standalone applicatlon; lt must be accompanled by a profect speclflc supplemental appllcatlon. -Fees will be collected at intake. Additionalfees may apply after review and payment is required before permit is issued. For Department Use Only Related Application #s: Building Permit # MLA # Site lnformation AssessorTaxParcelNumber: o21324oog Site Address and/or Directions to Property:485 Griffith Point Rd Nordland, WA 98358 Access (name of street(s)) from which access will be gained: Griffith point Road Present use of property: Residential Description of Work (include proposed uses): This property is served by Port Townsend or Port Ludlow sewer system? lf not served by sewer identified above, identify type of septic system below: YES NO { A* "th"-"sidences connected to the septic sy$em? Additions or repairs to sewage system: ls it a complete or partial system installation: Has a reserve drainfield been designated? Date of Last Operations & Maintenance check: Describe or attach any drainfield easements, covenants or notices on title, which may impact the property: Case #: Unknown {v- Type of ./ Sewage System Serving Property: Complete Yes Partial No- Attach last report to appllcadon Septic Community Septic Septic Permit f: Name of System: !-tI I II Wastewater - Sewage Disposal The authorized agent/representative is the primary contact for / e-mail requests and information about the application to the ; below. The authorized application. lt is the of the email is not or sent to all project-related questions and correspondence. The County will mail authorized agent/representatlve and will copy (cc) the owner noted parties involved with thethe information to all owner to ensure their mailbox accepts County email (i.e., k Applicant/Property Owner lnformation _{_ Please contact Authorized Agent/Representative with project info. (select only one} Property Owner Signature: Date; Address:485 Griffith Point Rd. Nordland. W498358 Property Owner: Name: Edward Savidge Phone S: 360-301-9902 E-mail Address: esavidge@olypen.com Note: For proiects with multiple owners, attach a separate sheet with each owner(s) information and signatures. Applicant: Authorized Agent/Representative (rf other than owner) Name: Address: Phone S: Bill Rehe 8305 Doowood Lane NW. Gio Harbor WA 98332 253-389-0712 E- m a i I Add ress : bilt@northforkenvironmenlal.com Professional:ls this an Authorized Agent/Representative for this project?NO YES Engineer Name: Address: Phone fl: Architect E-mailAddress: ConsultantSurveyorContractor License S Professional:ls this an Authorized Agent/Representative for this project?NO YES Engineer Name: Address: Phone *: Consultant E-mailAddress: Architect Surveyor Contractor License S Professional:ls this an Authorized Agent/Representative for this project?NO YES Engineer Name: Address: Phone #: Architect Surveyor Consultant E-mailAddress: Contractor License # 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 issqpd permit null and void. Signatu //PrintName: EDortVtO fr SA,nCeC Date: DEPARTMENT OF COMMUNITY DEVELOPMENT 6?l Shcridan Sreet, Port'f<rwnscnd, \!'.\ 98368 TeL 360.319.4,*50 | Fa-x: 360.379.4451 Web: r*rxrv.co. icffcrson.wz. us / c<xnmunirrtlcveloomcot E-nrail: dcdl-it)co.ic ffe.nion.rva.us SU PPLEMENTAI. AP PLI CATION SHORELINE DEVELOPMENT iD lirllriivLr trGtr[VIE JETTIRS()i,I C(]U,\' A form is a uirement of submittal. lnclude in By signing this form,attests in any is true 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 Owner Signature t Case #MtA # Apdication Type (select one): Variance*Substantial Danelopment*Statement of Exemption- See Examples on back side of application Conditional Use (administrative)* Does your proposal require in water work and/or works below ordinary high water mark? Yes { No Does your pronncal requiro 1n,000 sq/ft or more of impervious surface andlor non-single family structures of 5,000 sq/ft or more? Yes No { Conditional Use (discretionary)* 1) 2l Site lnformation Assessor Tax Parcel #:a21324009 Name of Body of Water:Kilisut Harbor Property Owner Name(s)Edward Savidge Project Description Describe the existing property use and condition: The property is currently used as a single family residence Proposed distance from ordinary high water mark to useldevelopment: Describe the proposed work that requires a shoreline permit or permit exemption: The existing bulkhead is failing and needs to be replaced in order to protect the single family residence from damage. Print Name Date ' li j mn 14 2018 I ,t t lf 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.