Phone: (360) 337-5777
Form Number: 1103D
Email: help@kitsap1.com
Page 1 of 1
SUPPORTING DOCUMENT
AUTHORIZATION FORM
Property Owner Name: _____________________________________________________________________
Permit Application Number: _________________________________________________________________
Assessor Tax Parcel #: ____________________________________________________________________
Project Name/Description: __________________________________________________________________
I (owner) hereby give __________________________________, authorization to act as my agent in obtaining
permits as required for the purpose of the project identified above.
I affirm, under penalty of perjury, that all answers, statements, and information submitted with this application
are correct and accurate to the best of my knowledge. I also affirm that I am the owner of the subject
site. Further, as owner, I grant permission to any and all employees and representative of the County of Kitsap
and other governmental agencies to enter upon and inspect said property as reasonably necessary to process
this application. I understand, in accordance with the Department of Community Development fee policies, the
base fee is determined by an average processing time. If staff hours required to process the permit exceeds
the base fee, additional charges may be incurred, and I agree to pay all fees of the County that apply to this
application. I understand refunds may also be issued for those permits that require less processing time.
By submitting this form, the property owner acknowledges and agrees that upon approval of this application a
Land Use Binder will be recorded by the Department of Community Development. Recording fees are at the
applicant’s expense. This Binder will include information directing inquiring public to the land use decision and
conditions contained therein. The Binder cannot be removed or extinguished without the written approval of
the Kitsap County Department of Community Development. Land Use Binders are applicable to:
Administrative Conditional Use Permits and Amendments; Conditional Use Permits and Amendments; and
Performance Based Developments and Amendments.
________________________ ___________
Property Owner’s Signature Date
________________________ ___________
_________________________
Property Owner’s Printed Name
_________________________
Property Owner’s Printed Name
Kitsap County Department of Community Development
614 Division Street, MS-36
Port Orchard, WA 98366-4682
www.kitsapgov.com/dcd/
Revision Date: 10/13/2021
Property Owner’s Signature Date
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