HomeMy WebLinkAboutBLD2022-00362-01- Permit ApplicationRECEIVED BY DCD 6/29/22
The authorized agent/represen�lve 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/representatlve 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 I box accepts County email (i.e.Coun email Is not blocked or sent to "'unk mail" .
.,..,._.,1u Owner Information
Property Owner:
Name:
Address:
Phone#: E-mail Address:
___ Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature:
Name:
Address:
Phone#:
Engineer
Name:
Address:
Phone#:
I:
Professlonal:
Engineer
Name:
Address:
Phone#:
Professional:
Engineer
Name:
Address:
Phone#:
If other than 0111ner)
E-mail Address:
Is this an Aut orized Agent/Representative for this ro·ect?
Architect Surveyor Contractor
License#
E-mail Address:
Is this an Authorized Agent/Representative for this project?
Architect Surveyor Contractor
License#
E-mail Address:
Is this an Authorized Agent/Representative for this project?
Architect Surveyor Contractor
License#
E-mail Address:
Date:
NO
Consultant
NO
Consultant
NO
Consultant
YES
YES
YES
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 itsemployees, repr esentatives or agents for the sole purpose of application review and any required later inspections. Applicant may
request notice of th� Coun�s intent t�f nter upon the property for visits relate .. d to this application and subsequen:pe:'"it issuance.
Signature: I ,UJ'.'.), A ubr:e.lJv_ Print Name: Kave, Al ))te L-�t Date: � v)� 'ufl,2-,-,
P1..:rnut \pph..:.!l111n P.1' ·.e 2 nl 2
RECEIVED BY DCD 6/29/22
RECEIVED BY DCD 6/29/22
RECEIVED BY DCD 6/29/22