HomeMy WebLinkAboutBLD2022-00391-01- 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:
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901081022
413 Southport Lane, Port Townsend, WA 98368
1101 - Residential - MH W/Land
Minor Modification to existing wireless communication tower. See attached project description.
N/A
N/A
N/A
N/A
N/A
RECEIVED BY DCD 7/5/22
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: ______________
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PATRICIA L. FITZGERALD & JON R. VOELKER
430 SOUTHPORT LANE, PORT TOWNSEND, WA 98368
✔
07/05/22
Crown Castle on behalf of AT&T (Kimberly Conley)
C/O GMA Network Services, LLC - 590 1st Ave S, #705, Seattle, WA 98104
(253)686-7155 kimberly@gmanetworkservices.com
✔
✔
Kimberly Conley - GMA Network Services, LLC
590 1st Ave S, #705, Seattle, WA 98104
(253) 686-7155
kimberly@gmanetworkservices.com
POD Group - Mark Edward Patterson
✔
✔
53055
11490 Bluegrass Pkwy, Lousville, KY 40299
(502)437-5252
Kimberly Conley 07/5/2022Kimberly Conley Digitally signed by Kimberly
Conley
Date: 2022.07.05 09:24:03 -07'00'
RECEIVED BY DCD 7/5/22
The Foundation for a Wireless World
CrownCastle.com
1505 Westlake Ave N, N
Seattle, WA 98109
Phone: (206)336-7382
www.crowncastle.com
Project Description
413 SOUTHPORT LANE
PORT TOWNSEND, WA 98368
RECEIVED BY DCD 7/5/22