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6E500-vOalB
. ¢,SON cod JEFFERS")COUNTY 411
a
i ill' -�,4 DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
p� www.co.jefferson.wa.us/commdevelopment
"QS NG`t
Master Permit Application MLA:
Project Description(include separate sheets as necessary):
Ni i,4A ) (',o (4)i '4
Tax Parcel Property
Number: j C, 0 C) 0 0 11 `"' Size: (acres/square feet)
Site Address and/or Directions to Property: 1 3 9 S i \ 2 e 4
Property Owner(s)of Record: -1 I\v ) L�, Nc}0C0/
•
Telephone: �r-L'lt 11)-1 'b`1 sax.Cxx. 2-ii0--Lig%•- t 1) ) email:
Mailing Address: ( ,-i ►t An/KA
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies)
❑ Building ❑ Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
❑Garage Attached/Detached ❑ Special Use(Essential Public Facilities)**
❑Manufactured Home ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat--
❑ Commercial* ❑ Binding Site Plan'"`
❑ Change of Use 0 Long Plat**
❑Address El Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments**
)ropane ❑ Plat Vacation/Alteration**
O Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions**
II Stormwater Management ❑ Shoreline Management Substantial Development**
CI Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
❑Temporary Use C] Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment
Li Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
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,her or it's 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 this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further 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.Access and right of entry to this property shall be requested and shall occur only during regular business
hours. J
Signature: �' vti 1. . •2 ) � Date: 72 )J C 1 _
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfe le responsibility for adheri to and complying with the ESA. The Applicant has read this disci ' errand signs'and` dates it below.
Signature: .0yvv��` C l - 'l r� Date: i� 2-i/) o Y
G:\PemutCenter\ RMS\DRD FORMS\Master Permit Application 7-8-04.doc
OWNER BUILDER STATEMENT •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
-fa‘v) yfko Vo,1\e_
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:(
MAILING ADDRESS: EMAIL
Project Type: Frame Type: I Bathrooms: Shoreline: Type of Sewage Disposal:
❑ New f7 Wood Existing: ❑ Sewer
❑ Addition ❑ Steel Proposed: Bank ❑ Community System
O Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System
❑ Repair H Masonry SEP Permit#
❑ Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: ❑ Public
Total: Name of System:
If this is a Commercial Protect you must answer the following:
Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces:
Number of occupants(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply:
❑ Underground Tank )c_Above ground Tank _ Size of Propane Tank: t 2 t; LN, (c
❑ Heat Stove ❑ Cook Stove [J Woodstove Fireplace heart [1 Hot Water Tank ❑ Pellet St ve [_I Other
Is this appliance being installed in a Manufact red/Mobi!,,Home? Yes / No
When applying for a permit to install a propane must also submit a site plan showing all of the buildings,all property
lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components,
including the reserve area.
Square Footage For Office Use Only
Current Proposed Amount 1
Main Floor Consstency Review:
2r4u Floor Base fee: fC
3fa Floor Additional Section:
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee:
Unheated Basement Pot Wate`'Review fee:
Other Unheated 911/Rd Approach fee:
Garage/Carport TOTAL: $
Decks Receipt Number:
Other Cash/Check Number:
ESTIMATED COST(REQUIRED) Date:
.Fair market value of all labor and materials foundation to finish
Initials:
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
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