HomeMy WebLinkAboutBLD2007-00144 • • MLA07-00164
BUILDING PERMIT APPLICATION Review Type: I
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD07-00144 Received Date: 4/2/2007
SITE ADDRESS: 330 SEAMOUNT DR
BRINNON, 98320
OWNER: LLB PROPERTIES LLC PHONE: (503) 663-6278
30205 SE KELSO RD
BORING OR 97009-6017
SEAMOUNT ESTATES DIV 1
SUBDIVISION: Block: Lot: 25
PARCEL NUMBER: 993000025 Section: 29 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
REPRESENTATIVE: PHONE:
PROJECT DESCRIPTIOF NEW SFR W/ATTACHED GARAGE REPLACING MFH
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,366
VALUATION 276,926.00 ADD'L: 390 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: 1,077 HEAT TYPE: EEE
OCCUPANCY: R-3
OCCUPANCY: UNHEATED: # OF STORIES:
CONST TYPE: 5N OTHER: SHORELINE:
GARA
CONST TYPE: DECKLE 448 SETBACK:
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUBLIC
BEDROOMS: BATHROOMS:
Exist: Exist:
Prop: 2 Prop: 3
Total: 2 Total: 3
Routing Date: 4 Jzk 7 6 ' 1
Type Amount Paid By: Date: Receipt: AO
r�d/�aYe
Permit $1,984.95 KAS 04/02/07 89494 UV
ED
Plan Check $1,290.22 KAS 04/02/07 89494 MAY a4 2007
State Building Code $4.50 KAS 04/02/07 89494
Total: $3,279.67 Jefferson County Planning
& Building Department
BUILDING PERMIT •
Jefferson County Department of Community Development
621 Sheridan Street, Port Townsend, WA 98368
(360)379-4450 FAX (360)379-4451
PERMIT #: BLD07-00144 Received Date: 4/2/2007
SITE ADDRESS: 330 SEAMOUNT DR Issue Date 5/24/2007
BRINNON, 98320 Expiration Date 5/24/2008
OWNER: LLB PROPERTIES LLC PHONE: (503)663-6278
30205 SE KELSO RD
BORING OR 97009-6017
SEAMOUNT ESTATES DIV 1
SUBDIVISION: Block: Lot: 25
PARCEL NUMBER: 993000025 Section: 29 Township: 25 N Range: 02 W
CONTRACTOR: OWNER/BUILDER PHONE:
PROJECT DESCRIPTION: NEW SFR W/ATTACHED GARAGE REPLACING MFH
TYPE OF WORK RES SQUARE FOOTAGE:
TYPE OF IMP NEW MAIN: 1,366
VALUATION 276,926.00 ADD'L: 390 HEAT TYPE: HTP
CODE EDITION: 2003 HEAT BASE: 1,077 HEAT TYPE: EEE
OCCUPANCY: R 3 UNHEATED: #OF STORIES:
OCCUPANCY:
OTHER:
CONST TYPE: 5N GARAGE: SHORELINE:
CONST TYPE: SETBACK:
DECK: 448
BANK HEIGHT:
SEWAGE DISPOSAL: CON
WATER SYSTEM: PUBLIC Type Amount Paid By: Date: Receipt:
BEDROOMS: BATHROOMS: Permit $1,984.95 KAS 04/02/07 89494
Exist: Exist: Plan Check $1,290.22 KAS 04/02/07 89494
Prop: 2 Prop: 3 State Building Code $4.50 KAS 04/02/07 89494
Total. 2 Total: 3 Total: $3,279.67
Directions to Site:
SEE. iA?CtLLe51- DER LTLuNS t MAPS
HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTION
THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED
BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS.
Office Hours 9:00 a.m. -4:30 p.m.
HOT LINE AVAILABLE 24 HOURS A DAY
SPECIAL CONDITIONS APPLY - SEE ATTATCHED
•Jefferson County Building Divion Permit Num.. BLD07-00144
Applicant: LLB PROPERTIES LLC
BUILDING PERMIT INSPECTION APPROVALS applicable Code: 2003 International Building Codes
To schedule inspections, call (360)379-4455 no later than 7:00 AM the day of the inspection.
Requests received after 7:00 AM will not be scheduled for that day's inspections.
ELECTRICAL PERMITS are issued by the Washington State Department of Labor& Industries.
The electrical permit must be signed off by the State Inspector prior to the County's Framing Inspection
Inspection Item Date Approval Signature Notes
Setbacks
Erosion Control
Foundation Footing
Footing Drains
Foundation Stem Wall
Underground Plumbing
Under Floor Framing
Straps(hold downs)
Ext. Shear Wall Nailing
Rough-in Plumbing
Framing
Blocking
Airseal
Insulation: Walls
Insulation: Floors
Insulation: Ceiling
Int. Shear Wall Nailing
Wallboard Nailing
Gas Line: Interior
Gas Line: Exterior
Propane Tank
Heat/Chimney Clearance
Drywell/Alt Drainage
Address Posted
FINAL INSPECTION
FINAL INSPECTION MUST BE APPROVED PRIOR TO BUILDING BEING OCCUPIED
THIS PERMIT IS VALID FOR ONE YEAR
•
CONDITIONS for Building Permit# :BLD07-00144
1.) PRIOR TO OCCUPANCY, REMOVAL OF THE EXISTING RESIDENCE PER BLD07-144
AND FINAL APPROVAL OF SEPTIC SEP07-21 ARE REQUIRED.
L
2.)' PRIOR TO FINAL BUILDING INSPECTION: MUST SUBMIT RECORDED NOTICE TO
0�t TITLE REGARDING THE SQUARE FOOTAGE OF HOME AND LIMITED CAPACITY OF
S'Qe�tIDRAINFIELD.
3.) PrMUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC
TANK, RESERVE & DRAINFIELD. MUST COMPLY WITH ALL PERMIT CONDITIONS,
STATE AND LOCAL CODE.
4.) The application was reviewed by the Jefferson County Department of Community
Development staff on May 23, 2007 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:
spotted owl/osprey; unstable shoreline slopes, landslide hazard area 1; SUSC aquifer
recharge area; coastal SIPZ.
5.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological
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.
6.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions
that promote rapid infiltration of recharge waters to groundwater aquifers.
7.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type,
geologic material, and groundwater that may combine to create problems with slope
stability, erosion, and water quality during and after construction or during natural events
such as earthquakes or severe rainstorms.
8.) Marine shorelines and islands are susceptible to a condition that is known as seawater
intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in
an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater
suitable for public consumption without significant additional treatment and cost.
Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of
the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater
withdrawals (primarily through wells). The Washington Department of Ecology is the
agency with statutory authority to regulate groundwater withdrawal for individual wells in
Jefferson County. New development, redevelopment, and land use activities on islands
and in close proximity to marine shorelines in particular should be developed in such a
manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to
the maximum extent possible by infiltrating stormwater runoff so that it recharges the
aquifer.
9.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according
to the County GIS map. There are voluntary and mandatory measures identified in the
Jefferson County Seawater Intrusion Policy (Resolution 44-22, effective September 23,
2002) that apply to well drilling proposals and building permit applications on existing lots
of record.
A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine
shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources
within 1000 feet.
10.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
11.) To help prevent seawater from intruding landward into underground aquifers, all new
development activity on Marrowstone Island, Indian Island and within 1/4 mile of any
marine shoreline shall be required to infiltrate all stormwater runoff onsite.
12.) The property owner shall comply with Water Conservation Measures (per list maintained
by the UDC Administrator).
13.) The applicant is proposing to creSr add 1020 square feet of impervious sulk and
1404 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your
proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution
Prevention) of the Department of Ecology Stormwater Management Manual for Western
Washington 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.
14.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP)
Elements #1 through #12 of the Department of Ecology's Stormwater Management
Manual for Western Washington 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.
15.) 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.
16.) 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).
17.) The site plan as submitted with the building permit application on April 2, 2007 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 May 23, 2007 shall be resubmitted for review and
approval by Jefferson County Department of Community Development.
18.) This approval is for a single family residence w/attached garage that is replacing an
existing manufactured home to be removed 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.
19.) Outdoor residential storage shall be maintained in an orderly manner and shall create no
fire, safety, health or sanitary hazard.
20.) Not more than 2 unlicensed vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor
vehicles is prohibited except in those districts where specified as an autormobile wrecking
yard or junk (or salvage) yard and allowed as a permitted use in Table 3-1 or Chapter
18.18 JCC, and such storage shall meet the requriements of JCC 18.20.100, Automobile
wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor
vehicles be stored in a critical area.
21.) Exterior lighting for residential uses 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.
22.) 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.
23.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of
impervious surface which includes roof tops, driveways, concrete, etc.
24.) The building height is not to exceed 35 feet.
25.) Minimum setback from Seamount Drive right-of-way shall be 20 feet. Minimum side and
yard setbacks shall be 5 feet and minimum rear yard setback shall be 25 feet to the
property line and 10 feet from the 15 foot access easement for the benefit of Lot 24.
26.) A minimum of two on-site parking spaces shall be provided for the single family residence.
27.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive
Land Use Map effective August 28, 1998.
28.) An address of 330 Seamount Drive, Brinnon has been assigned to the parcel. Seamount
Drive is a county local access (C206909).
29.) The lot was created through the lenount Estates Division 1 Subdivision on PlOst 18,
1969 under AFN 201980.
30.) A septic permit (SEP76-0181) was finaled on July 29, 1976 and is now filed with
SEP07-0021 that was approved on March 9, 2007.
31.) The parcel is served by Seamount Estates Community water system. Potable water was
proven at time of manufactured home installation in 1973.
32.) The parcel slopes to the south. The North corner has an elevation of 127 feet and drops
to 105 feet at the west corner over a length of 120 feet. According to the county GIS
maps, the subject parcel has a gradual slope to the road. The road and parcels to the
southwest, south, and southeast are where the steeper slopes are more accurately
depicted.
33.) The proposal was not sent to WDFW as osprey are no longer a priority species and the
identified eagle's nest is greater than 1100 feet to the north of the subject parcel.
34.) A Declaration of Restrictive Covenant was recorded on April 25, 2007 under AFN 522762
due to the limited capacity of the septic system to two bedrooms.
35.) The recorded plat (8/18/69) identifies a 15 foot wide access easement on the northeast
boundary. This easement is for the benefit of Lot 24. The existing manufactured home
was placed on the parcel in 1973 as was the existing gravel driveway to said residence.
The proposed permit is to replace the manufactured home with a stick frame house in
approximately the same location. The same access will be utilized as the septic and
components between the county road and the proposed residence. The attached covered
porch is approximately 12 feet to the access easement and the attached garage is 10
feet. JCC Table 6-1 Note 3 allows the administrator to reduce the front yard setback if
strict application of such setback would render a legal lot of record unbuildable.
Therefore, due to the topography, placement of septic and components, the administrator
hereby grants a reduction to 12 feet from the platted access easment to the covered porch
and a 10 foot reduction from the closest point of the attached garage to the platted access
easement.
t
41' •
0006, JEFFERSO v COUNTY
W •
� ,\ 1 DEPARTMENT OF COMMUNITY DEVELOPMENT
I' v = 1'4 621 Sheridan Street • Port Townsend •Washington 98368
360/379-4450 • 360/379-4451 Fax
�qS, 0 www.co.jefferson.wa.us/commdevelopment
Master Permit Application MLA: ,' "
Project Description (include separate sheets as necessary): G"Xi.%i,3 /1/f/i—,.1 n' <<-'.?--'-c. t(`L'l i i c n ii t -... <
ra`i.tAi t'<.e s i�> •t) t~ !-. - s ,_c i./ A X M biz'L�
Property
Tax Parcel Number: 7 r1 L C)cep _5. Size: (acres/square feet)
Site Address and/or Directions to Property: •Z 6 c.; ,,49inc%�%IL v12 6'/,,,,i.- .i. G41 -/g 3 L(-
Property Owner(s)of Record: L t 3 1'/ZF.%i c/`'7/�S (..-.L c:
Telephone: ,`4.=fy -E:�:3 t`=L-) e Fax: >L3- 6-.•S --72-2 2 email: 7 A •'
Mailing Address: ' ram-- Lc- .5.- �: f i c:C.iu ie'...,d• ;; .,?i . ,
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 Reasons e `Cis ' ;
❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]�II .4 to ��A�
/Single Family ❑ Discretionary"D"or Unnamed Use Classification
`Garage L Attach> Detached ❑ Special Use(Essential Public Facilities)**p r n A 9 ?nn7❑ Manufactured Home ❑ Boundary Line Adjustment ;
❑ Modular ❑ Short Plat**
❑ Commercial* ❑ Binding Site Plan**
IDChange of Use ❑ Long Plat** � i iliMi) f[
❑ Address C1 Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
ropane ❑ Plat Vacation/Alteration**
❑Allowed "Yes" Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions**
❑ 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* 0 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 Al>b(','=l rile kw.._ to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE /��1 _,-‘ , ///._ ._ �� � �� p 3/3 G/C
By signing this applications form,the owner/agent attests that the information provided herein, d 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 regyfred later inspections.Access andjght of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: .7' „.z_____. Date: '/ •)()7 b , -
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 velopment code.The Applicant acknowledges that he,she or it holds individual and non-
transferable respo, ' ility fo adhering to and;complyi g ith the ESA. The Applicant has read this disclaimer and signs and dales it below.
Signature: �" t /fr--� -4- s- Date: �/i c/c 7
G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc
• • 1
BUILDER STATEMENT
The signer of this statement does hereby certify hat they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will be ass ftg a responsibility of the Gdneral Contractor for the proposed project.
Signature:, G 3 /.3 ti C�g �>! 'tom �..t`_..-- Date: __ .3J 7
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX: ( )
MAILING ADDRESS: EMAIL
Pjoject Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
New Wood Existing: LI Sewer
❑ Addition ❑ Steel Proposed: =. Bank Height: ❑ Community System
❑ Alteration/Remodel Concrete Total: °'� Individual System
❑ Repair r❑ Masonry S P Permit# C 7- .:1_./
LI Demolition ❑ Other: Bedrooms: Water Supply:
Existing: Setback: ❑ Private well ❑ Two Party
Type of Heat: Proposed: 'z.- Public
If cM-T . ;n../' Total: ..- 'Name of System:•%4rir 4,c,•-
s
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:
I i Underground Tank ' Above ground Tank Size of Propane Tank:
CI Heat Stove ❑ Cook Stove I I Woodstove ❑ Fireplace Insert Hot Water Tank Pellet Stove [I Other
Is this appliance being installed in a Manufactured/Mobile Home? Yes /flo
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 lines, buildings and septic system components,
including the reserve area.
Square Footage Current Proposed For Office Use Only Amount Revision
Main Floor Heated f? C .��� Cj5 EH Bld App Review: p°
2n°Floor Heated ! �� O 7"l Consistency Review: i n „,..,
.
Other Heated Base fee:
1 °I -q5
Mezzanine Additional Section: ,_,.,.,_ _-_—
Heated Basement 1 7 C53 f.51 Plan Check fee: aQ
Unheated Basement State Surcharge fee: /
SD
Other Unheated Pot Water Review fee:
eyA
idi
Garage/Carport _ Z SUBTOTAL5�
124��I , 3 '(or/
Decks qbeb,j). 911/Rd Approach fee:
il/(r E-R-(ST- - "1
Other e) �o
. .. 3 -Z `154.2-4 TOTAL: $ U. 7
__ Receipt Number: $-t 4 Git1
C a2(.��l(o9 Cash/Check Number: GO 1 rG
ESTIMATED COST(REQUIRED) Date: t �J
•Fair market value of all labor and materials foundation to finish Q 4( f 67
C!% Initials:
( Ka.)-.-
zy// ( D .
G:\PermitCenter\FORM3'<DRD FORMS\Master Permit Application 12-30-05.doc
�.¢,S01v cow JEFFERSON COUNTY
W ,,1 DEPARTMENT OF COMMUNITY DEVELOPMENT
`' ' ` ! 621 Sheridan Street • Port Townsend • Washington 98368 1111
360/379-4450 • 360/379-4451 Fax
�q p� www.co.jefferson.wa.us/commdevelopment
S NGZ
Master F erm't Application MLA:
( Project Descriptio elude separate sheets as necessary): r?Er't")(' x1�r�'�' .>asr"z✓Sirc7:.cc'! /./Asia 'C
NG d4,,,e
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rl3 3r, ��r9�Tv c�Air ,�g, t3,2i.✓.Uc.iti• /9 9f33Z��
Tax Parcel Property
Number. 'Sr7q :3 DOG 0 2 S Size: :L g '96( /Z/ °(:3 's-.c.'"(acres/square feet)
Site Address and/or Directions to Property:
3 36 LS .r1.7No o iv 7 ii,R, J,3 rc-r;„);-v iivv lAivi .3 Z c)
Property Owner(s)of Record:
Telephone: Fax: email:
Mailing Address:
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
What kind of Permit?(Check each box that applies
❑Building 0 Variance(Minor, Major or Reasonable Economic Use)
❑ Demolition Permit 0 Conditional Use[C(a),C(d),or C]**
❑ Single Family ❑ Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification
❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)**
❑ Commercial* 0 I3oundary Line Adjustment
❑ Change of Use 0 Short Plat**
❑ Address 0 Road Approach 0 Binding Site Plan**
❑ Home Business 0 Cottagelndustry ❑ Long Plat**
❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments**
❑Sign 0 Plat Vacation/Alteration**
0 Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions*`
0 Stormwater Management 0 Shoreline Management Substantial Development**
❑ Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Variance
0 Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment
0 Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment -''
0 Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request
*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: 'x'
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 materia 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 re d later inspection . Staffs s and right of entry will be assumed unless the applicant informs the County in writing at the
time of the appl. n t at he or he wa is prior ti
Signature: /J Date: '/ — - U 7
The action 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 issu will not violate the ESA. An . dividual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if re in compliance with the on County development code.The Applicant acknowledges that he,she or it holds individual
and non-transf ' le r ponsi lity for heri�j and plying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
000
K. Signature: Date: — 7
G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc
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