HomeMy WebLinkAbout01- Permit ApplicationSON �o DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, A'A 98368
W Tel: 360.379.4450 1 Fax: 360.379.4451
\Veb: www.co.Jefferson.wa.us/communindevelopment
F.-mail: dcd&,co.jefferson.wa.us
I N G�O�
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: 001334021
Site Address and/or Directions to Property:155 Night Owl Rd, Port Townsend, 98368
Access (name of street(s)) from which access will be gained:
Four Corners Rd.
Present use of property: Vacant land
Description of Work (include proposed uses): Construction of single family residence and detached shop
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? N.
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:
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.,
uounty email is not t)IOCKeo or sent to " unK mail-,).
Applicant/Pronertv Owner Information
Property Owner:
Name: Charles and Heather Southard
Address: 8087 Lars Dr NE, Bremerton WA 98311
Phone #: 360-917-6281 E-mail Address: charles.southard@gmail.com
Please contact Authorized Sgent/Representative with project info. (select only one).
Property Owner Signature: �,� Lae_c ' 4'-- C!taz6zi Date: 7Ze
Note: For projects with multiple owners, a46ch 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 C unty's intent t e upon the property for visits related to this application and subsequent permit issuance.
Signature Print Name: /'� ����- l Date: