The URL can be used to link to this page

Home My WebLink AboutApplicationsDEPARTMENT OF COMMUNITY DEVELOPMENT Sheridan Street, Port Townsend,1�!/A 98368 Tel: FA3 360.37).4450 1 Pax:360.379.4451Web: E-mail: dcdfc�r co.icffcmon.wa.ux r ! JAN 3 o 2019 PRE -APPLICATION CONFEREefRSONCOUNNoM The Jefferson County Code (JCC) 18.40.090 & 18.25.640 requires that before an application is made for all Type II and Type III project applications and Type I applications proposing impervious surfaces of ten thousand (10,000) square feet or more and/or non -single family structures of five thousand (5,000) square feet or more, or all projects involving in -water work or work below OHWM, a pre -application consultation must be held. The consultation includes preliminary review and administrative assistance. This service does not include extensive field inspection or correspondence. Pre -application consultation does not limit subsequent administrative review. At the conference, Department of Community Development personnel shall provide the applicant with: (1) A list of the requirements for a completed application; (2) A general summary of the procedures to be used to process the application; (3) The references to relevant code provisions or development standards that may apply to the approval of the application; and (4) A list of any applicable hourly review fees that may be charged by one or more County agencies upon the filing of a project permit application with the County. Discussions at the conference or the information provided by the staff shall not bind or prohibit the County's future application or enforcement of all applicable laws and regulations. No statements or assurances made by County representatives shall in any way relieve the applicant of his or her duty to submit an application consistent with all relevant requirements of County, state and federal codes, laws, regulations and land use plans. NAME: VVIV NE MAILING ADDRESS: TELEPHONE: (HOME) C, - &'e7 � "'T % EMAIL REPRESENTATIVE: MAILING ADDRESS: ((, C (.G TELEPHONE: (HOME) :20 I EMAIL DIRECTIONS 1. Please answer all questions on this form completely. 040V 2. Attach one sketch of the Conceptual Design for the proposed use or activity, showing the following information: a. Vicinity sketch; b. North arrow and scale; c. Property boundaries and identification of land uses on adjacent properties; d. Means of ingress and egress; e. Property/lot drainage; f. Possible locations of sewage disposal and water supply systems; g. Location of utility easements; and h. Proposed location of buildings, including setbacks to property boundaries. 3. Attach payment of the applicable fee, as set forth in the Jefferson County Fee Ordinance. �,�5� &Po Z�NI�I-�00O1 m ... ...... ...... ........ Property Description General Location: p=k^ Legal Description (from Property Tax Statement): 9-Digit Parcel Number (from Property Tax Slalomont): CLn_L2_t C7 Total Acreage: - Zone: - c`� G %Lot Covamge: Applicant: XOwner t ❑ Lessee ❑ Contract Purchaser ❑ Other Project Description Standard Disclosure Information provided to a prospective applicant during the pre -application consultation Is based on County regulations In effect at the time of the pro -application consultatlon. 13oviseti or ew Cou re utatio s u!d a a t a fuitl a da a ication. A pre - application consultation does not vest a future development application. By signing the application form, the applicant/Owner attests that the Information prodded herein is true and correct to the best of their knowledge, I also certify that this application Is being made with the full knowledge and consent of all owners of the affected Property. Any material falsehood or any omission of a material fact made by the applicant/owner vAlh respect to ibis application packet may result In [his permit being null and void. I further agree to save, indemnify and hold harmless Jefferson County against all liabilities, Judgments, court costs, reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. further 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. This right of entry shall expire when the County (through the Administrator a Administrator's representatives) concludes the application has complied with all applicable laws and regulations. Access and t�Iry to [he appl' nl's property shall he requested and shall occur only during regular busl ss hours. (slcrurur�) (o E)- to act as my agent in matters related to this pre -application 1 2 8 21�1r' (DATE) a-FOAMSNSADRrYPr. AL*Vw pp mnbrmco f°rmdoo REV. t lnfl013 Page 2 Scanned by CamScanner DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street, Port Townsend, VIA 98368 Tel: 360.379.4450 1 Fax: 360.379.4451 Web: Wy-w. f % ieffyrson.w,"ts/sommunitliI. vclo mcnt PERMIT APPLICATION JAN Steps in the Permit Process: F � -Review application checklist to ensure all information is completed prior to submitting appp �TdrQ01jJ, -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: Q 0 1213 d r Site Address and/or Directions to Property: $011 H FF ivow 2 C., Pnr' Tni niZPA. lli aA, Access (name of street(s)) from which access will be gained: Present use of property: Description of Work (include proposed uses): ryy— Pevejtpmen�-; Per- SeJP_SV0rMe j jp Wastewater - Sewa3 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: Complete Partial Has a reserve drainfield been designated? Yes No l` 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: CnM 16 -Loy Z3 �LA SFr Deco � 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., Countv email Is not blocked or sent to "sunk mail'I. Applicant/Property Owner Information Property Owner: / Name: _L11o/JN6 hGnJ .,y�Q 16, Address: 3O (1 hJ 2 r_W _�y 0uJS -7 Phone #: E-mail Address: Please conta thorized AS t/Representative with project info. (select only one). c- Property Owner Signature: e Date.1, -;7 ew r Note: For pro ects with multiple owners, attach a se arat cet with each ownerls) information and signatures. Applicant: Authorized Agent/Representative (If other than owner) Name: omr- Address: Ve, T 11 Phone It: E-mail Address: bfV(0? Professional: Is this an Authorized Agent/Representative for this project? NO YES Engineer V Architect Surveyor Contractor Consultant Name: ZZFMLicense it Address: `7 17 A-5t. PortAnyelP5,Z Phone #: w -T .7I kJE-mail Address: Z+AL t ' ' 1k , ' 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 ff 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 age is for the sole purpose of application review and any required later Inspections. Applicant may request notice of ounty's Inte to enter upon the property for visits related to this application and subsequent permit d ssuance. el Signature: Print Nam&a^►' �7-D Date: / -7