Revised 02/27/2014
OFFICE USE ONLY
PROPERTY OWNER INFORMATION Contact Person
Name:
Mailing Address:
City/State/Zip:
Phone: Phone:
Email:
Name:
Mailing Address:
City/State/Zip:
Phone: Phone:
Email:
APPLICANT INFORMATION Contact Person
Development Permit Applicaon
Pacic County Department of Community Development
Internet Address: www.co.pacic.wa.us
Authorized Signature: Date:
SOUTH BEND OFFICE
P.O. Box 68
South Bend, WA 98586
(360) 875-9356 FAX (360) 875-9304
LONG BEACH OFFICE
7013 Sandridge Rd.
Long Beach, WA 98631
(360) 642-9382 FAX (360) 642-9387
DESCRIPTION OF WORK
Legal Descripon and Tax Parcel Number can be found on your tax statement, the Pacic County web site address listed above or by calling the
Assessors oce at 360-642-9301 or 360-875-9301. Applicaons cannot be processed without this informaon.
Printed Name:
Note: If your property is in a current use program (mber, farm, agricultural, or open space), contact the Assessor before applying, as taxes may be due.
All permits shall be picked up within 30 days of nocaon by the Department of Community Development that the permit is ready for issuance. Failure to pick up
the outstanding permit(s) and pay all outstanding fees within the specied meframe shall result in the forfeiture of all permit documentaon and all applicaon
fees paid to date on that project. Any subsequent perming on the same parcel by the same property owner requires the submial of new permit applicaon
materials and the payment of all new fees at the me of applicaon.
I authorize employees and ocials of Pacic County and/or the Flood Control Zone District No. 1 of Pacic County the right to enter and remain on the property in
queson to determine whether a permit should be issued and whether special condions should be placed on any issued permit. I have the legal authority to
grant such access to the property in queson.
I also acknowledge that if a permit is issued for land development acvies, no terms of the permit can be violated without further approval by the perming
enty. I understand that the granng of a permit does not authorize anyone to violate in any way any federal, state, or local law/regulaon pertaining to develop-
ment acvies associated with a permit.
I hereby cerfy under penalty of perjury under the laws of the State of Washington that the following is true and correct:
1. I have read and examined this development applicaon, as well as the County site-plan checklist and have documented all applicable requirements
on the site plan.
2. The informaon provided in this applicaon contains no misstatement of fact.
3. I am the owner(s), the authorized agent(s) of the owner(s) of the above referenced property, or I am currently a licensed contractor or specialty
contractor under Chapter 18.27 RCW or I am exempt from the requirements of the Chapter 18.27 RCW.
4. I understand this permit is subject to all other local, state, and federal regulaons.
Note: This applicaon will not be processed unless the above cercaon is endorsed by an authorized agent of the owner(s) of the property in queson and/or the owner(s)
themselves. If Pacic County and/or the Flood Control Zone District No.1 of Pacic County has reason to believe that erroneous informaon has been supplied by an author-
ized agent of the owner(s) of the property in queson and/or by the owner(s) themselves, processing of the applicaon may be suspended.
Job Site Address: Tax Parcel ID No.:
Legal Descripon: Township/Range/Secon / /
JOB SITE INFORMATION AND LOCATION
Direcons to Site:
Issued Date:__________________________
Issued By: ___________________________
PERMIT FEES:
All documents and informaon submied in conjuncon with this applicaon is subject to Public Disclosure in accordance with RCW 42.56
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