HomeMy WebLinkAboutBLD2021-00500 - 01 Permit ApplicationPermit Application Page 1 of 2
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | 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 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:
Site Address and/or Directions to Property:
Access (name of street(s)) from which access will be gained:
Present use of property:
Description of Work (include proposed uses):
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: Complete 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:
with (6) antennas; (12) radios with (6) radios and replacing the existing mount on the existing tower.
Center Road and NF1161
1219 Center Rd, Chimacum, WA 98325
N/A
N/A
N/A
N/A
N/A
Commercial Forrest property with an existing unmanned wireless facility.
901231004
Verizon is proposing to modify their existing wireless facility by replacing (12) antennas
Permit Application Page 2 of 2
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:
Address:
Phone #: E-mail Address:
Please contact Authorized Agent/Representative with project info. (select only one).
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:
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:
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 the County’s intent to enter upon the property for visits related to this application and subsequent permit issuance.
Signature: Print Name: Date: ______________ Renata Fayten
1717 S. Boulder Ave, Suite 300
919-661-6351
326 Tryon Road, Raleigh, NC 27603
4
4
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renatasoffice@gmail.com
C/O GMA Network Services - PO Box 2006, Bellevue, WA 98009
Crown Castle on behalf of Verizon (Renata Fayten)
08/20/21
Renata Fayten
Tower Engineering Professionals
C/O GMA Network Services - PO Box 2006, Bellevue, WA 98009
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3425
425-269-5561
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425-269-5561
Chimacum Ridge LLC
B+T Group (John Welton Kelly III)
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renatasoffice@gmail.com
52921
721 NW 9th Ave #200, Portland, OR 97209
Renata Fayten
918-587-4630
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