HomeMy WebLinkAboutBLD2021-00069-01- PERMIT APPLICATIONDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street,PottTownsend,WA 98368
Tel:360.379.4450 I Fax:360.379.4451
Web:www.co.jefferson.wa.us/communitydevelopment
E-mail:dcd@co.jefferson.wa.us
PERMIT APPLICATION
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 applicatlon;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#
Site Information
Assessor Tax Parcel Number:
Site Address and/or Directions to Property:
Access (name of street(s))from which access will be gained:
,.0 v'V'.c...c'K A-v
Present use of property:e...,.S \"d...e..M.ce....----~~~~~~===7---------,~------------------~------------~
Description of Work (include proposed uses):--t:.:b:WU'...3::t.c.~--~L~i>I:..Q..l'r.'IJlM.JA,10QL~:l...E~1+.bJUU~
Wastewater -Sewage Disposal
This property is served by Port Townsend or Port Ludlow sewer system?YES NO V
If not served by sewer identified above,identify type of septic system below:
Type of Sewage System Serving Property:
~Septic Septic Permit #:~\2f>1,q-00334
Community Septic Name of System:S ~~t\..~'M-e.;c TIJ prusuce.Case #:ss«.([)O ~?y
Are other residences connected to the septic system?rd tn
Additions or repairs to sewage system:
Is it a complete or partial system installation:Complete ./Partial
Has a reserve drainfield been designated?Yes ///No
R -If .-~'O
,
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:
v1 J ~.-f-c.-&~~s\~.DL'-".,-
\
Permit '\prUC.Ult}Jl lJa~L 1 ot 1.
authorized agent/representative is the primary contact for all project-related questions and correspondence.The County will mail
f 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 mai Ibox accepts County email (i.e.,
County email is not blocked or sent to "junk mail").
Applicant/Property Owner Information
Property Owner:
Name:S\I\o.-fO n <:K o...ciu.-
Address:C;-:2,I..{r ~1\k..-4.\.t e .l=='\.[-t-¥E:I(,-\-\0\.););'\~(>AI\.J .•wA G)X'&log
Phone #:~(o 4--03 358'(p E-mail Address:5hn.x-0I'1 A -<'a....Jc.r @ \\\Ie ,C-evv"
Please contact Authorized Agent/Representative with project info.(select only one).
Property Owner Signature:,.~J Q 0 .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-rnail 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:
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 com pliance 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 not~.:=_.AJo.u!,ntentto enter upon the property for visits <elatedto this applicationand subsequent permit l"uan'1,
Signature~,.rr,O -==Print Name:S bGUfl>v\J?a,J"..c Date:1-~7 -•.
Pernur -\OPitCHIOIl Pa~....2 ot 2
I
DEPARTMENT OF COMMUNIlY DEVELOPMENT
621 Sheridan Street,Port Townsend,WA 98368
Tel:360.379.4450 I Fax:360.379.4451
Web:www.co.jefferson.wa.us/cornmunitydevelopment
E-mail:dcd@co.jefferson.wa.us
SUPPLEMENTAL APPLICATION
RESIDENTIAL OR COMMERCIAL BLDG PERMIT
For Department Use Only
Related Application #s:
Receipt#:Date:
Payment #:
Site Information
Owner Name:5hoC&Y\Ka.,L.c Assessor Tax Parcel #:~qCJoo7~03
Type of Building
NewL Replacement Relocated-----
Addition Repair Demolition *------
*A separate permit is required
Select One:
Single Family Residence Modular OtherL list------
Proposed Building/Project
Number of floors ~#new bedrooms e>existing total bed
bo...-R h<!:l v S e #new bathrooms ,existing total bathS·t~a-Lohe..
Heat Source
Select all that apply:
Electric ./Heating Oil Wood Propane
Structure Existing Sq/Ft Proposed Sq/Ft ICC Valuation (Office Use)
Residential/Commercial Main Floor
Residential/Commercial Second Floor
Additional Floors -heated /unheated
Basement -unfinished
Basement -finished space or habitable
Detached Garage -heated /unheated
Attached Garage -heated /unheated
Garage 2nd fl -unfinished storage
Garage 2nd fl -finished space or habitable
Carport -2 walls or less
Deck -uncovered
Covered porch 0 ~
Other (shed,barn,pole bldg,etc.)~oxI.'h ~1.f,e,..CJ ~-;;...
Estimated Cost of Project (Required):$$
Enter the square footage (sq/ft)that applies in each field:
~uppk'mcilul SFR 1
I
unit,shed,barn,mobile home,other:
Builders Statement
The signer of this statement certifies that they are the Owners of the parcel referenced herein,that they are not licensed
contractors and that they will be assuming the responsibility of the General Contractor for the proposed project.
Signature:~~Print Name:1)~~'<1RQW Date:·j-J..7-;l.1
->
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 t this ap lication packet may result in making any issued permit null and void.
Signatur Jit..~:....=l:~~Print Name:~S=--:Yl~of=-...;...o_n~~_~_...;;....;;::.-=--__Date:/-~?-;;)..(
I For Department Use Only I
Building Permit Fees
Zoning
$288.00
$139.00
$139.00
$24.00
$6.50
Building Base
Plan Check Review
Land Use Review
Septic Review
Potable Water
Technology/Scan
State Fee
Other Fees
Shoreline Exemption
Zoning
Other
New Address
Technology Fee -5%
Total Fees
Receipt #Date:Cash/Check/CC:
Supolemcntal ::;lcR _