HomeMy WebLinkAboutZON2022-00037_01A permit applicationDEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Steet, Port Townsend, \\A 98368
Te1: 360.379.4450 | Fax: 360.379.4.+51
\.eb: wwrv.co.ie flferson.wa.us /commururrdeveloomen t
E -mail: dcd@co.iefferson.rva.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
Related n #s:
Building Permit #
MLA #
Site lnformation
Assessor Tax Parcel Number: 001 061 005
Site Address and/or Directions to Property: 231 Middlepoint Road, Port Townsend, WA
North on Middlepoint Road. Left at fire markers 223 & 221. Property at end to the left ol shared road. No access yet by car
Access (name of street(s)) from which access will be gained:
From Hastings to Middlepoint Road
Present use of property: Undeveioped land
Description of Work (include proposed uses): Clearing & grading lor driveway & utilities.
clearing for site work ol the proposed Single Family Residence.
Wastewater -Disposal
This property is served by Port Townsend or Port Ludlow sewer system?
lf not served sewer identified above,of
Type of Sewage System Serving Property:r' Septic
YES
below:
Septic Permit #: To be Designed & Perrnitted
NO
Community Septic Name of System: N/A
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:
Case #:
N14
N/A
Complete
Yes
Partial
No _ /_
Attach last report to application
Describe or attach any drainfield easements, covenants or notices on title, which may impact the propefi:
N#A
for Driveway access and utilities.
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
the information to all parties involved with the
owner to ensure their mailbox accepts County email (i.e.,
Applicant/Propefi Owner I nformation
Please contact Authorized Agent/Representative with project info. (select only one).
Property Owner Signature: Date: 8/01 DA22
E-mail Address: suzannelizette@gmail.com
Property Owner:
Name: Suzanne Carlson
Address: 1431 Washington St.
Phone #: 360-379-3005
Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and signatures.
Applicant: Authorized Agent/Representative (rf other than owneri
Name:
Address:
Phone #:E-mailAddress
Engineer
Name:
Address:
Phone #:
Consultant
E-mailAddress
NO YES
7t< 6'r-o*t =+, 3d dA ta*avbc--azl- 7?bo
Professional ls this an Authorized for this
Architect Surveyor Contractor
License #
Professional ls this an Authorized ABent/Representative for this project?NO YES
Engineer
Name:
Address:
Phone #:
Consultant
E-mailAddress:
Architect Surveyor Contractor
License #
Professional: ls this an Authorized Agent/Representative for this project?NO YES
Engineer
Name:
Address:
Phone #:
Architect Consultant
E-rnail Address:
Surveyor 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
all applicable federal, state and county laws and regulations
complete associated with this permit will be performed in compliance with
and I agree to
of application
provide access and right of entry to Jefferson County and its
employees, representatives or agents for the sole purpose review and any required later inspections. Applicant may
request notice of s intent to enter upon the property for visits related to this application and subsequent permit issuance.
Signatu re:
Cou
Print Name .Suzanne Carlson garc.8lO1l2O22