HomeMy WebLinkAboutBLD2021-00640 - 01 Permit Application
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:
Permit Application Page 1 of 2
RECEIVED BY DCD 10/26/2021
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: ______________
Permit Application Page 2 of 2
RECEIVED BY DCD 10/26/2021
JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street | Port Townsend, WA 98368
360-379-4450 | email: dcd@co.jefferson.wa.us
www.co.jefferson.wa.us/commdevelopment
BUILDING PERMIT REVISION
Date
Regarding: Building Permit Number
Address
Parcel Number
Other Case Number/s
Submitted by: Phone:
Submittal Explanation (what’s being revised?):
Please complete the following, if applicable:
Permit Type & Square Footage
PERMIT TYPE: APPROVED SQ/FT: CHANGE TO SQ/FT: TOTAL SQFT:
Commercial
Residential
Garage/Shop
Accessory
Uncovered Porch
Covered Porch
Unfinished Basement
Other (Specify)
Estimated Fair Market value cost of changes:
No change to square footage
6.20.22
BLD2021-00640
55 Snider Peak Lane, Port Ludlow, WA 98365
978802018
Cliff OBrien 360-301-3179
Revised plot plan to show a 3 car garage (2 car garage plot plan was submitted in error)
489
1695 1695
752
0
263
$32,875
RECEIVED BY DCD 6/21/2022
Estimated Fair Market value cost of changes:
If the revision involves structural and/or floor plan changes, the following is required:
A narrative describing the changes and page number in set of plans where change occurs
Two copies of only the revised building plans - clearly marked by a border/bubble
Two copies of revised floor plan on no larger than 11x17
Minimum fees:
Plan Check - $97.00
Land Use - $97.00
Administrative - $97.00
Environmental Health - $141.00
Environmental Health - $71.00 - Review of resubmission before Building Permit is approved
Technology Fee - 5% of total fees
If the revision involves changes to the site plan, the following is required:
A narrative describing the changes on the site plan- if they were requested by a department
please note who requested them
Two copies of the revised site plan on no larger than 11x17 – revisions clearly marked by a
border/bubble
Minimum fees:
Administrative - $97.00
Land Use - $97.00
Environmental Health – will be invoiced by EH, if needed, after review
Plan check fees may apply if a revision to the building plans is needed
Technology Fee - 5% of total fees
Fees shall be collected at the time of re-submittal. Revisions that go beyond the minimum revision time
during Plan Check, Land Use review, and Environmental Health review will be charged an additional
hour. Any additional fees that are accrued during the revision process must be paid prior to the approval
and issuance of the revised permit.
All revisions to structural components or plans that previously included structural engineering will need
to have the revision wet stamped and signed by a design professional (engineer, architect etc.) licensed
in WA state.
Please route copy to:
EH: Planning: PW: Building:
Office use only
Please Check with DCD for total fees
RECEIVED BY DCD 6/21/2022