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HomeMy WebLinkAboutBLD2005-00724 CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD05-00724 SITE ADDRESS: 425 FREDERICKS ST Issue Date: 12/29/2005 PORT TOWNSEND, 98368 Final Date: 07/14/2006 APPLICANT: CRAIG W GOSS PHONE: 360-385-3914 CAROL E GOSS 2156 14TH ST PORT TOWNSEND WA 983688227 SUBDIVISION: COVE ADDITION Block: 4 Lot: 1+ PARCEL NUMBER: 945900402 Section: 16 Township: 30 N Range: 01 W PROJECT DESCRIPTION: NEW MAN HM THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: mow ad Now., ` IIio ogo er TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes `--__. J n� � � r� THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 07/14/2006 Building Official Signature Date I:\F_BLD_Occupancy,rpt 10/29/19f • • MANUFACTURED/MOBILE HOME INSTALLATION Jefferson County Department of CommunityDevelopment Devvelopm PERMIT 621 Sheridan Street, Port Townsend, WA 98368 360 379-4450 FAX 360 379-4.451 PERMIT#: BLD05-00724 SITE ADDRESS: 425 FREDERICKS ST PORT TO Received Date: , 98368 APPLICANT: Issue Date: 11/17/2005 CRAIG W GOSS 12/29/2005 TOWNSEND CAROL E GOSS `zA 2156 14TH ST l - SUBDIVISION: PORT TOWNSEND WA 983688227 COVE ADDITION PARCEL#: Block: 945900402 Section: 16 Township: Lot: CONTRACTOR/ OWNER/BUILDER 30 N Range: 01 W DEALER PHONE: PROJECT DESCRIPTION: NEW MAN HM MAKE: KARSTEN YEAR: 2006 SIZE: 60 X 26.8 THIS PERMIT IS VALID FOR ONE THE FINAL INSPECTION MUST E SCHEDULED AND PASSED YEAR. CALL IN FOR THE THE EXPIRATION DATE IS 12/29/2006. THIN THAT YEAR. REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED Stormwater FINAL Approval: Blocking/Plumbing: '1 Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: I l� HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPS RLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a, HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY-SEE REVERSE 411, MLA05-00677 MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00724 Received Date: 11/17/2005 SITE ADDRESS: 425 FREDERICKS ST PORT TOWNSEND, 98368 APPLICANT: CRAIG W GOSS PHONE: 360-385-3914 CAROL E GOSS 2156 14TH ST PORT TOWNSEND WA 983688227 SUBDIVISION: COVE ADDITION Block: Lot: PARCEL NUMBER: 945900402 Section: 16 Township: 30 N Range: 01 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MAN HM TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: KARSTEN SETBACK: VALUATION 67,000.00 YEAR: 2006 LABOR & INDUSTRIES APPROVAL? SIZE: 60 X 26.8 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: CITY BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: I I \ 1405 V12-, Type Amount Paid By: Date: Receipt: APIDPOS /EE' Permit $157.00 SLE 11/17/05 77424 Potable Water Application $53.00 SLE 11/17/05 77424 DECoZ°( 2005 Total: $210.00 ie#erson County Planning .& Budg Department _ r Ce2 &.. JACK WESTERMAN 11 Jefferson flirty Courthouse ASSESSOR 1'O Box OW, Port Townsend,1111A 98368 (360)385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: COPY NAME: a A 1 01- � i', S _ ��j-�, `� ADDRESS: 15 ' l L(�� tor. `J[ J !' k/L) C '4 q ,06-- PRONE NO. 3 , C 3 g 5 T3 c// The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. l)MOBILE HOME DATA: (A)MAKE Ic A { 1 S .CA/ (B)MODEL iipzi4e,dSzctgft (C)YEAR 9 (D)LENGTH C ' (E)WIDTH .)6 (F)ERA# ` I Le"Y) �/I (G)YOUR PURCHASE PRICE(Do not include sales tax) (7 (,' PURCHASE DAT t L G 2)PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE ADDRESS (B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No If Yes, Previous address of mobile. If No,What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes NO (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE HOM PARK: NAME OF LAND OWNER: C� P. L � % n LOCATION ADDRESS 4405 F( )��`6'c (C. c j pro ��� 40 REAL PROPERTY PARCEL#/DESCRIPTION ) c .)06 r 2 t ` Si nature of applicant THANK YOU FOR YOUR HELP! NOV 1 7 2005 6C�sst Q Q JO COSSELL, Property Technician • • SPECIAL CONDITIONS CASE # BLD05-00724 1.) Dry well must be located a min. of 10' upslope of any portion of the septic system. 2.) The application was reviewed by the Jefferson County Department of Community Development staff on December 8, 2005 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: SUSC aquifer recharge area. 3.) Aquifer Recharge Areas in Jefferson County are characterized by porous formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 4.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 5.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 6.) The applicant is proposing to create or add 2750 square feet of impervious surface and 9650 square feet of land disturbing activities. 7.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 8.) A Stormwater Site Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 9.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i). 10.) The site plan as submitted with the building permit application on November 17, 2005 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated December 8, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 11.) This approval is for a manufactured home only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 12.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 13.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any lot less than one-half acre unless totally screened from view of neighboring dwellings and rights-of-way. Such screening shall meet all applicable performance and development standards specific to the district in which the storage is kept, and shall be in keeping with the character of the area. Screening shall meet the requirements of Unified Development Code (UDC) Section 6. Outdoor storage of thirteen (13) or more unlicensed or inoperable vehicles is prohibited except in those districts where specified as an automobile wrecking yard or junk (or salvage) yard and allowed as a Permitted Use in Table 3-1 of the UDC, and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area (ESA). 14.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 15.) The building height is not to exceed 35 feet. • 16.) Exterior lighting for residentiaTuses shall not exceed twenty feet 20 in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 17.) Lighting fixtures shall be designed and hooded to prevent the light source from being directly visible from outside the boundaries of the property. The intensity or brightness of all lighting, during construction and after project completion shall not adversely affect the use of surrounding properties or adjoining rights-of-way. 18.) Minimum setback from Frederick Street right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 19.) A minimum of two (2) on-site parking spaces are required for the manufactured home. 20.) This parcel is a legal nonconforming parcel designated Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 21.) An address of 425 Fredericks Street, Port Townsend has been assigned to the parcel. Frederick Street is a county local access (C693419). 22.) A septic permit(SEP05-0355) was approved on November 14, 2005. 23.) These lots were created through the Cove Addition subdivision September 27, 1889 through the Cove Addition Plat recorded with the Jefferson County Auditor under Vol 2, P 27. 24.) The parcel is served by the City of Port Townsend water system. 25.) A Boundary Line Adjustment was finalized on June 8, 1998 and recorded on June 12, 1998 under AFN 411539 to consolidate Lots 1 &2 with Tax 60 (west 1/2). 26.) MANUFACTURED HOMES INSTALLATION SET UP MANUAL MUST BE ON SITE FOR ALL INSPECTINS AND A ADDITIONAL INSTALLATION MANUAL MUST BE SUBMITTED TO JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT y� :,,, .• / /17 • RETURN ADDRESS L47STATE Or WASH/NGTON MANUFACTURED HOME PLEASE CHECK ON licEnsinc APPLICATION ®TITLE ELIMINATION ❑TRANSFER IN LOCATION ❑REMOVAL FROM REAL PROPERTY Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a tine,imprisonment,or both. (RCW 46.12.210) ® MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 Karsten 64/26.8 ® LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ®AFFIXED ElREMOVED REAL PROPERTY TAX PARCEL NUMBER 945 900 402 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 1-2 ,4 Cove Addition to the City of Port Townsend © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 I NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Tony N.Taylor NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Chelsey L. Taylor ADDRESS CITY STATE ZIP CODE P.O. Box 145 Port Hadlock WA 98339 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Countrywide Bank,FSB NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 19980-10th Ave NE, Suite 201 Poulsbo WA 98370 GRANTEE NAME Tony N. Taylor and Chelsey L. Taylor I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE:Signature of Registered Owner and Title,IF APPLICABLE -2. %4� Signature,� 4Q'aItRegistered Owner and Title,IF APPLICABLE `.<2. la STAigtt i NOTARIZATION/CERTIFIC ' N FOR ISTERED 0 ' ER(S)SIGNATURE • ft: State of Washington ,' (j; ,„' 7 Signed or attested /Q-• 00\0 Y 9� yJ County of Jefferson before me on .nuary 30,2008 I . �,S O�Q'� �y Tony N.Taylor Signa[ure / ' z , !, , , • G : 5, ! PRINTED NAME OF REGISTERED OWNER -... •O 0 \� I- 44411. I! ••(J �� �, y Chelsey L.TaylorI QQ _ r +, P ��'• PRINTED NAME OF REGISTERED OWNER /\ _ (� 1/t ••••.• 1U:..• �\� "PRINT AM OF NO ••Y I` it, tS' 3 '� County/Office No.OR II T•••"•"' .v,,��= Title Notary AND: Dealer No.OR . ��x tt TE O DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date t U III TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER First American Title Of Jefferson County (360)385-1322 SIGNATURE/POSITION DATE ©Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. BUILDING PERMIT OFFICE CERTIFICATION I certify that: the manufactured home has been affixed to the real property as described. a building permit has been issued for this purpose and the attachment will be inspected upon completion. 194IVE?TytED OR PRINTED) LDG P RMIT FF E/P NE# B(` ` r�k Sv1� Y tor 1 - 4 L56 1 ' 905-7 a4 SITU /PO IT N �/0` ^ n w DAE (Xy TD-420-72 MANUF MEAPPPL •L11((R//22/02)EXT(W))\JPaWgeVI oof22 ,\311D" • I MANUFACTURED HOME—FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 Karsten 64/60 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE Signature of Additional Legal Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of Jefferson before me on by Signature PRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date DLAND DESCRIPTION(A legal description of the land can be obtained from the local County Assessor's Office.) See Attached Exhibit"a" DEALER'S REPORT OF SALE I CERTIFY,THAT THIS INFORMATION IS CORRECT,THE VEHICLES IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORIZED SIGNATURE 0 USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). 9 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICE/VFS OPERATOR NUMBER SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX IMPORTANT: Once the application has been approved by the County Auditor/Vehicle Licensing Office,take your application form to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form,obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must retum to a Vehicle Licensing office to file the Manufactured Home Application, paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this form for Title Elimination,Removal from Real Property or Transfer in Location,see form TD-420-730,Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation,please call(360)902-3600 or TTY(360)664-8885. TD-420-729 MANUF HOME APPL(R/2/02)EXT(W)Page 2 of 2 �_ OWNER BUILDER STATEMENT 0 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 Gene Contractor for the proposed project. ) /��_____ Signature: Date: / GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Ty pe of Sewage Disposal: New Wood Existing: ❑ Sewer 0 Addition ❑ teel Proposed: Bank 0 Community System 0 Alteration/Remodel 0 Concrete Total: Height: ❑ Individual S tem - 0 Demolition Ir ❑ Masonry SEP Permit €-U Other: Bedrooms: Water Supply:c'O 3.57 Existing: Setback: ❑ Private well 0 Two Party T f Heat; Proposed: ��- Total: Public Name�f S tem:d _• CCTA If this is a Commercial Project 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 ❑ Above ground Tank Size of Propane Tank: ❑ Heat Stove 0 Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank 0 Pellet Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you 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 fines,buildings and septic system components, including the reserve area. Square Footage For I.4601#Only r :'Current Proposed Main Floor N YReviey. Al•- U 'mt'.. ; v i , . , . � r 3 s a J t Sr � k'.t;2NUFloor 2Trgu: . 7. dtlonal-Sectlotr, t 'Y3roFloor v t ar r NOV 1 / 2005 w Mezzanine: 1 ~'fan Check fee: `.- ..� Heated Basement "•' Unheated Basement -" :., t y ' a . 4'' Other Unheated r7 0.} t} u t . r t 5► 3 Garage/Carport ,, 7 TQTAL:, Decks r .L iF ' t4 � � ? Other • C ShlCheck Nuri> ier" ` _ '� 5 ESTIMATED COST(REQUIRED) Date .. '•� ' ., , , " .Fair market value of all labor and materials foundation to finish � �,���l���,� Initials: ' ott, \ G:\Perm \ itCenter\FORMS\DRD FORMS Permit Application 7-8-04.doc IP i.;ON- 6.AiIii& JEFFE N COUNTY alr DEPARTMENT OF COMMUNITY DEVELOPMENT r'' ` '"4` 621 Sheridan Street• Port Townsend •Washington 98368 NOV 1 2.005 360/379-4450 • 360/379-4451 Fax �q p� www.co.jefferson.wa.us/commdevelopment $ING Master Permit Application MLA: 6 5-c-77 Project DP�.ription(include separate sheets as necessary): Tax Parcel Property /0�/'1 Number: C/ q7 CA)6 L/ C. Size: / /) f/ (acres/square feet) Site Address and/or Directions to Prorty: `') Flu- Fes`'`j (C i` J S ii 1 / c/ ./ Property Owner(s)of Record: (", ({0 L Uc5 c 4L2PL s libTelephone:,3 (r ) 3 ) - T3 7I Fax: J email: $4. �2 (a', cf)4 Mailing Address:(9(``' / ((Nth 5: 4---/ 1/e '6 r&k--/jV C��/ 1�- .�% I Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: at kind of Permit?(Check each box that applies) h 7Building ❑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 Xarage Attached/Detached CI Special Use(Essential Public Facilities)** anufactured Home ❑ Boundary Line Adjustment odular ❑Short Plat** ❑Commercial* ❑ Binding Site Plan** ❑Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)IAmendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** El Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ 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 ! / n 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 attorney'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 a right of entry to this property shall be requested and shall occur only.during regular business hours. -- Signature: ec.,.4.,4 ,_./-6,--,j Date: l ,r. 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 ateurances 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-transfera ile responsibili for ad ring to and complying with the ESA. The Applicant has read this disdaimef and s' ns and dates it below. Signature: a.C 0.i1-j Date: r///y 3 G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc