HomeMy WebLinkAbout01- Land Use Applicationl)f."Y.\R"t \I frlXT OI"C0 lI trI t.r N ITY DE\rI1LO Pl.{ }i}.J'T
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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
Related Application #s:
Building Permit #
MLA #
Site lnformation
AssessorTaxParcel Number: qL3 - 3A3' I bL{
Site Address and/or Directions to Property: | 47 A er' Loo ? Qo. * Ic.-,,, g e", a(
Access (name of street(s)) from which access will be gained: I vl Z ttrtL I aoL.
Present use of property: i? e n, { c, {
Description of Work (include proposed uses): gL, o - I f ,, ^ B"-,ln (
Wastewater -
This property is served by Port Townsend or Port Ludlow sewer system? YES
lf not served by sewer identified above, identify type of septic system below:
Type of Sewage System Serving Property:
X Septic te? lq qq -oot17Septic Permit #:
Name of System:Case #:Community Septic
Are other residences connected to the septic system?
Additions or repairs to sewage system:
NO
svt L
ls it a complete or partial system installation: Complete
Has a reserve drainfield been designated? l0 -ZV.ZO71jV"t
Pa rtia I
No
Date of Last Ooerations & Maintenance check:
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
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. ltistheresponsibilityoftheauthorizedagent/representativeandownertoensuretheirmailboxacceptsCountyemail (i.e.,
Countv email is not blocked or sent to "lunk ma
Applicant/Propertv Owner Information
Property Owner:
Name: f?cn a"[ o( (L tc a
Address: "7 9 O9 H,^klcf Oc,k O, Ue,,
Phone #: YZt lf O n t 11 E-mail Address: Gcv, i? rce @. f?c- tZ tce . A)c f-
Please contact Authorized Agent/Representative with project info. (select only one).
Property owner Signature: | ,?,.^-Date: (t' Zz'ZZ
I
Note: For proiects with multiple owners, attach a separate sheet with each owner(s) information and signatures.
Applicant: Authorized Agent/Representative (rf other than owner)
Name:
Address:
Phone #E-mailAddress:
Professional: ls this an Authorized Agent/Representative for this project? NO YES
Engineer
Name:
Address:
Architect Surveyor Contractor
License #
Consu ltant
Phone #:E-mail Address:
Professional: ls this an Authorized Agent/Representative for this project? NO YES
Engineer
Name:
Address:
Architect Surveyor Contractor
License #
Consu ltant
Phone #E-mailAddress:
Professional: ls this an Authorized Agent/Representative for this project? NO YES
Engineer
Name:
Address:
Phone #:
Architect Surveyor Contractor
License #
Consu ltant
E-r'nail 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 theCpntV's intent to enter upon the property for visits related to this application and subsequent permit issuance.
ll 'L - r / ->signature: /i / w Print Name: (a^ u[c( lZ, c e Darc' b'23'z L