HomeMy WebLinkAbout01-Permit ApplicationDEPARTMENT OF COMMLINITY DEYELOPMENT
621 Sheddan Street, Port Townsend, WA 98368
Tel: 360379.1450 | Fax: 360.379.4451
Web: vrvw.co.iefferson.wa.us/cr-mmuniwdevelooment
E - mail: dcd(Oco.ieffcrson.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 proiect 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 #
MLA#Related lication #s:
Site lnformation
o5
--7Site Address and/or Directions to Property:
Assessor Tax Parcel Number:
Access (name of street(s)) from which access will be gained:
Description of Work (include proposed uses):
Present use of property:
Wastewater -
This property is served by Port Townsend or Port Ludlow sewer system?YES Nox
identify type of self not served sewer identified above below
Are other residences connected to the septic system?
Additions or repairs to sewage system:
ls it a complete or partial system installation:
Has a reserve drainfield been designated?
Date of Last Operations & Maintenance check:
Describe or attach any drainfield easements, covenants or notices on title, which may impact the property:
dA+Type of Sewage System Serving Property
Case #
Attach nrt r"port to application
Septic
Community Septic
Septic Permit #:
Name of System:
Partial
No
Complete
Yes
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DCD RECEIVED 12/02/2022
The authorized agent/representative is the primary contact for
/ e-mail requests and information about the application to the
all project-related questions and correspondence. The County will maii
authorized agent/representative and will copy (cc)the
parties involved
owner noted
the information to all with the
owner to ensure their mailbox accepts County email (i.e.,
Applica nt/Property Owner I nformation
E-mail Address: -{i_r *.r. ".n-U = e-tr- @ ,rWfA] \
contact Authorized Agent/Representative with projecfinfo. (select on-fy one). Jtp ,-,
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Property Owner:
please
Property Owner Signature:
Name:
Address:
Phone #:
Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and signatures.
Applicant: Authorized Agent/Representative (rf other rhan owner)
Name:
Address:
Phone #:E-mailAddress:
Professional:ls this an Authorized Agent/Representative for this project?NO YES
Engineer
Name:
Address:
Phone #:
/- Architect Surveyor
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Consu lta nt
'Z(^ - $Lt- qql& E-mailAddress:
Contractor
License #
Professional:ls this an Authorized Agent/Representative for this project?NO YES
Engineer
Name:
Address:
Phone #:
Architect Su rveyo r Consu lta nt
E-mailAddress:
Contractor
License #
Professional:ls this an Authorized Agent/Representative for this project?NO YES
Engineer
Name:
Address:
Phone #:
Arch itect Consu lta ntSurveyor
E-mailAddress:
Contractor
License #
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
and I agree to provide access
permit will be performed in compliance with
all applicable federal,and county laws and regulations and right of entry to Jefferson County and its
employees,or agents for the sole
request notice of
ication review and any required later inspections. Applicant may
visits related to this application and subsequent permit issuance
purpose of appl
the property for
Print NameSignature
unty's intent to enter upon
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DCD RECEIVED 12/02/2022