HomeMy WebLinkAbout01A - PERMIT APPLICATION (0002)Permit 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:
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: ______________
email is not
E-mail Address: olia.kezhner@gmail.com; john 4020@gmail-com
Authorized Agent/Representative with project info. {select only one}
DateSnlner
WAWATownsend,Tr 983681DrivePortownsend,Bellevue9836860dePortLaneChantal,772
Property Owner:
Olia
508 353-9521
Please
Name:
Address:
Phone #:
information andsheet with eachattach aNote: For with
Name:
Address:
Phone #:2A6-842-5514
1100 NW
Bruce
Fload, Poulsbo, WA 98370
E-mailAddress: bruce@
Engineer
Name:
Address:
Phone #:
Arcftitea SurveYor
Bruce MacLearnsberry
r' contractor
License #
Consultant
Road,WA 98370
206-842-5514
1100 NW
E-mailAddress: bruce@
Engineer
Narne:
Address:
Phone #:E-mailAddress:
ConsultantArchitectSurveyorContractor
License f
Engineer
Name:
Address:
Phone #:E-mailAddress
ConsultantArchitectSurveyorContractor
License #
By signing this application form, the owner/agent attests that the information provided herein, a-nd in any attachments' is true and
correct to the best of his or her'knowledge.' a-ny material falsehood or any omission of a materiai fact rnade by the owner/agent with
respect to this application packet may result in making any issued permit null and void'
lfurther agree to that all activities I intend to undertake or complete associated with this permit will be performed in compliance with
att ippiicaSte federal, stateinO county laws and regulations and I agree.to provide access and right of entry to Jefferson County and its
"*ptiy""r, representativut or" ig"ntt for the solJpurpose of application review and any required later inspections' Applicant may
|."ql"rt noiice'of the County's intint to enter upon ihe property for visits related to this application and subsequent permit issuance'
srenrrur*, M Print Namel Bruce Maclearnsberry - D31s;81412022
to
Professional:ls this an Authorized for this NO YES
Professional:ls this an for this NO YES
Professional: ls this an Authorized for this NO YES