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 Applicaon
Pacic County Department of Community Development
Internet Address: www.co.pacic.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 Descripon and Tax Parcel Number can be found on your tax statement, the Pacic County web site address listed above or by calling the
Assessor’s oce at 360-642-9301 or 360-875-9301. Applicaons cannot be processed without this informaon.
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 nocaon 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 specied meframe shall result in the forfeiture of all permit documentaon and all applicaon
fees paid to date on that project. Any subsequent perming on the same parcel by the same property owner requires the submial of new permit applicaon
materials and the payment of all new fees at the me of applicaon.
I authorize employees and ocials of Pacic County and/or the Flood Control Zone District No. 1 of Pacic County the right to enter and remain on the property in
queson to determine whether a permit should be issued and whether special condions should be placed on any issued permit. I have the legal authority to
grant such access to the property in queson.
I also acknowledge that if a permit is issued for land development acvies, no terms of the permit can be violated without further approval by the perming
enty. I understand that the granng of a permit does not authorize anyone to violate in any way any federal, state, or local law/regulaon pertaining to develop-
ment acvies associated with a permit.
I hereby cerfy 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 applicaon, as well as the County site-plan checklist and have documented all applicable requirements
on the site plan.
2. The informaon provided in this applicaon 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 regulaons.
Note: This applicaon will not be processed unless the above cercaon is endorsed by an authorized agent of the owner(s) of the property in queson and/or the owner(s)
themselves. If Pacic County and/or the Flood Control Zone District No.1 of Pacic County has reason to believe that erroneous informaon has been supplied by an author-
ized agent of the owner(s) of the property in queson and/or by the owner(s) themselves, processing of the applicaon may be suspended.
Job Site Address: Tax Parcel ID No.:
Legal Descripon: Township/Range/Secon / /
JOB SITE INFORMATION AND LOCATION
Direcons to Site:
Issued Date:__________________________
Issued By: ___________________________
PERMIT FEES:
All documents and informaon submied in conjuncon with this applicaon is subject to Public Disclosure in accordance with RCW 42.56
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signature
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