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Home My WebLink AboutSUB2025-00007_Exhibit#3_ApplcationPermit 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: ______________ Page 1 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: planning@co.jefferson.wa.us SUPPLEMENTAL APPLICATION LAND DIVISION PARCEL # PROJECT/APPLICANT NAME: PURPOSE The purpose of the land division permit process is to ensure consistency with the applicable sections of the JCC Title 18.35 (see below). Land Division – Short Plat, Long Plat, Binding Site Plan PROCESS 1.Schedule a Customer Assistance Meeting with a planner, a pre-application strongly encouraged. 2.Submit an application for land division showing how you meet the criteria below. 3.Determination of Completeness will be made by County staff within 28 days. 4.Application review and decision will be made by the County within 120 calendar days. 5.Upon approval, a “record of survey” document will be prepared and recorded with County Auditor. SUBMITTAL REQUIREMENTS 1.Five (5) paper copies of a preliminary plat meeting the requirements of Jefferson County Code (JCC) 18.35.110 and 18.35.120 for short plats, or JCC 18.35.290 and 18.35.300 for long plats/binding site plans and identifying points of access, all easements, deeds, restrictions, or other encumbrances restricting the use of the property, as applicable. Survey must be done by a licensed surveyor. Recording of Documents with the County Auditor: Upon approval of your BLA, a "record of survey" document must be prepared by a licensed land surveyor and recorded with the Jefferson County Auditor (see RCW 58.09 and WAC 332-130) within 90 days. 2.Where site conditions require a special report to assess or address any probable significant adverse environmental impacts, a study (or studies, as applicable) prepared by a competent professional may be required if deemed necessary by the Administrator. Required Submittal Items Permit Application Supplemental Land Division Application SEPA Checklist (if applicable) Certificate of Water Supply Utility Service Form Permit Fees, paid at application submittal Five (5) paper copies of a preliminary plat – see #3 for details below. Special Reports (if applicable) – see #2 for details below. Stormwater calculation packet Preliminary plat must be prepared for short plats and long plats. Page 2 3. The following supplemental information: I, ___________________________________, do hereby swear and certify that in addition to the land subject to this application (check the box below which applies):  I have no interest in  I have an interest in land within 300 feet of any portion of the subject property by reason of ownership, contract for purchase by agreement or option by any person, family member, firm, or corporation in any manner connected with me or the development. The applicant hereby certifies that the preliminary plat provides an accurate representation of the proposed land division; and the applicant hereby acknowledges that any approval issued on this application may be revoked if any such statement is found to be false. Signature Date Receipt #: Date: Cash/Check/CC: Subdivision Name: Land Use (check one):  Residential  Commercial  Industrial Total Acreage of Property: Total Lots Proposed: Water Supply (check one):  Individual Wells  Community Water System Sewage Disposal Method: Average Lot Size: Minimum Lot Size: Open Space: OFFICE USE ONLY Land Division Permit Fees Land Use Review – Long Plat $9,202.00; Short Plat $2,889.00; Binding Site Plan $9,202.00 DCD116 Notice of Application DCD116 $149.00 Notice Board DCD116 $12.00 Environmental Health – BLA Base Fee (no lots included) EH031 $243.00 Environmental Health – Per Lot Fee ($108.00/lot) EH034 Public Works– Short Plat $400.00; Long Plat $1,004.00 (5-8 lots); Long Plat $2,010.00 (8+ lots); Binding Site Plan $803.00 PW0100 Scan Fee DCD122 $26.75 Subtotal Technology Fee EH9999 – 5% Total Fees* *Additional fees may apply. Scan the QR Code to access the digital form