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Home My WebLink AboutBLD2021-00280 - 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: Apr 03 2021 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., 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 visits related to this application and subsequent permit issuance. Signature: Print Name: Date: ______________ Apr 03 2021 Supplemental SFR 1 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 SUPPLEMENTAL APPLICATION RESIDENTIAL OR COMMERCIAL BLDG PERMIT For Department Use Only Receipt #: Date: Related Application #s:Payment #: Site Information Owner Name: Assessor Tax Parcel #: Type of Building New Replacement Relocated Addition Repair Demolition * *A separate permit is required Select One: Single Family Residence Modular Other list Proposed Building/Project Number of floors # new bedrooms existing total bed # new bathrooms existing total bath Heat Source Select all that apply: Electric Heating Oil Wood Propane Enter the square footage (sq/ft) that applies in each field: 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 Other (shed, barn, pole bldg,etc.) Estimated Cost of Project (Required): $ $ May 17 2021 List existing buildings on property (i.e. house, garage, accessory dwelling unit, shed, barn, mobile home, other): All Existing Buildings on Property Use 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: Date: _____________ 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. Signature: Print Name: Date: Supplemental SFR 2 For Department Use Only $2 .00 $13 .00 $13 .00 $2 .00 Building Permit Fees Building Base Plan Check Review Land Use Review Septic Review Potable Water Technology/Scan State Fee $.50 Other Fees Shoreline Exemption Zoning Zoning Other New Address Technology Fee 5% Total Fees Receipt # Date: Cash/Check/CC: May 17 2021