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Home My WebLink AboutBLD2014-00318 ILDING PERMIT APPLICATIR BR D14-00318 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD14-00318 Received Date: 9/3/2014 SITE ADDRESS: 2755 TARBOO LAKE RD QUILCENE, 98376 OWNER: POPE RESOURCES PHONE: CIO OLYMPIC RESOURCE MGMT 19950 7TH AVE NE#200 POULSBO WA 98370 SUBDIVISION: Block: Lot: TX 1+ PARCEL NUMBER: 801181001 Section: 18 Township: 28 N Range: 1N CONTRACTOR: TBD PHONE: 253-584-6606 REPRESENTATIVE: LYNX CONSULTING PHONE: 206-972-1368 17311 135TH AVE NE SUITE A-100 WOODINVILLE WA 98072 PROJECT DESCRIPTIOP SPRINT PROPOSED TO MODIFY ITS ANTENNA EQUIPMENT TELECOMMUNICATIONS TOWER. THE OVER ALL HEIGHT OF THE TOWER WILL NOT INCREASE. ADDIND ADDITION OF 3 PANEL ANTENNAS, 3 RRHS, 6 CYLINDERS AND 1 FILTER. THERE ARE NO CHANGES AT THE GROUND LEVEL OR ANY SITE DISTRUBANCE. TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: TYPE OF IMP ALT MAIN: INDUSTRIAL: VALUATION 10,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: NUMBER OF EMPLOYEES: WATER SYSTEM: BATHROOMS: APPROVED Exist: Prop: SEP 2 9 2014 Total: Jefferson County DCD Routing Date: • SE33XC013 THIRD PARTY INSPECTION LETTER To Jefferson county: Here on site SE33XC013 we found that all sprint equipment that has been recently installed on this tower is installed per plan. All antennas are installed with the correct U-bolts, antenna hardware, and all is locked down with correct size lock washers, flats and nuts. CHAD ROOPER Construction Manager-Pacific Northwest *6.NI a sTc Network SOlutians 22263 south nEcolvE Kent WA A 9 980303 2 Office:253-480-2500 Mobile:503-969-5366 Emai:Chad.Rooper @Mastec.com n , SEP - 3 2015 www.mastecnetworksolutions.com H JEFFERSON COUNTY DEPT.OF COMMUNITY DEVELOPMENT SE33XC013 THIRD PARTY INSPECTION LETTER To Jefferson county: Here on site SE33XC013 we found that all sprint equipment that has been recently installed on this tower is installed per plan. All antennas are installed with the correct U-bolts, antenna hardware, and all is locked down with correct size lock washers, flats and nuts. CHAD ROOPER Construction Manager-Pacific Northwest Al"i Q T c Network Soiutions 22263 68`^ave south Kent WA 98032 Office:253-480-2500 Mobile:503-969-5366 Emai:Chad.Rooper@Mastec.com www.mastecnetworksolutions.com SE33XCO13 THIRD PARTY INSPECTION LETTER To Jefferson county: Here on site SE33XC013 we found that all sprint equipment that has been recently installed on this tower is installed per plan. All antennas are installed with the correct U-bolts, antenna hardware, and all is locked down with correct size lock washers, flats and nuts. • • fq r' r '1 DEPARTMENT OF COMMUNITY DEVELOPMENT 621 5heridvi Street,Port Townsend,WA 98368 T'cl 360379.4450 I Par.360379.4451 Web:www.co.Jefferson.ma.tlacommunit*velopment - - E-mail dckfalco.ielferson.We.us POPE RESOURCES C/O OLYMPIC RESOURCE MGMT 19950 7TH AVE NE#200 POULSBO WA 98370 RE: PERMIT RENEWAL SITE ADDRESS: 2755 TARBOO LAKE RD PERMIT it BLD14-00318 PARCEL: 801181001 DATE EXPIRES: 9/29/2015 PROJECT DESCRIPTION: SPRINT PROPOSED TO MODIFY ITS ANTENNA EQUIPMENT f, TELECOMMUNICATIONS TOWER. According to our records,your building permit will expire on 9/29/2015 and has not passed final inspection. Please either schedule a final inspection prior to expiration or submit a renewal payment in the amount of$234 to 621 Sheridan St„ Port Townsend,WA 98368 prior to expiration. You are welcome to make a payment online at: http://www.co.jefferson.wa.us/commdevelopment/Credit%20Card.htm To schedule an inspection, please contact our inspection hotline at 360-379-4455 and have your approved permit and plans available on-site. If you have any questions about your permit,you can contact our office at 379-4450 between 9:00 a.m.and 4:30 p.m. Monday through Thursday. Thank you, Elizabeth Williams Administrative Clerk SITE ADDRESS: 2755 TARBOO LAKE RD PERMIT it BLD14-00318 PARCEL: 801181001 DATE EXPIRES: 9/29/2015 PROJECT DESCRIPTION: SPRINT PROPOSED TO MODIFY ITS ANTENNA EQUIPMENT TELECOMMUNICATIONS TOWER. PAYMENT ENCLOSED: $234 HlidemarkldataVormslF_BLD Permt_Exp_ktc.rpt • • Mary Blain From: Mary Blain Sent: Friday,August 28, 2015 1:43 PM To: 'azavales @lynxconsulting.org' Subject: third party verification letter This is in regards to a Final inspection that was called in for BLD14-00318;a Sprint modification to existing cell tower at 2755 Tarboo Lake Rd. A third party letter from a WA state Engineer,verifying the installation was completed per plan will need to be submitted,and will count as,the final inspection for this building permit. Please have the letter either mailed to Sally Ellis at the address below,or emailed to her at sellis @co.iefferson.wa.us Best, Mary Blain Plans Examiner I Dept of Community Development 621 Sheridan St Port Townsend,WA 98368 ph: 360-379-4461 fax: 360-379-4451 mblain@co.iefferson.wa.us All e-mail sent to this address has been received by the Jefferson County e-mail system and is therefore subject to the Public Records Act,a state law found at RCW 42.56.Under the Public Records law the County must release this e-mail and its contents to any person who asks to obtain a copy(or for inspection)of this e-mail unless it is also exempt from production to the requester according to state law,including RCW 42.56 and other state laws. 1 i i Sally Ellis From: Sally Ellis Sent: Friday, September 19, 2014 10:50 AM To: 'Aileen Zavales' Subject: RE: Status of zoning and BP approval for Sprint 82962 at 2755 Tarboo Lake Road, Quilcene Good Day Aileen, I have checked the status of this permit BLD14-00318. It looks like we are waiting on one more review from the Planner/DRD person whom is Tim, and the final review from the Plan Examiner. We also will need for you to provide the contractor information for this permit. Our Plan Examiner is not in the office today- I will have to follow up with him on Monday and see if his review is done. It should not be much longer. I do hope this information is helpful. Sincerely Sally L Ellis Jefferson County Community Development Permit Technician 621 Sheridan St. 7 Port Townsend, WA 98368 360-379-4452 scllis @co.jefferson.wa.us YY From:Aileen Zavales [mailto:AzavalesPlynxconsulting.orq] Sent: Friday, September 19, 2014 9:53 AM To: Sally Ellis Subject: Status of zoning and BP approval for Sprint 82962 at 2755 Tarboo Lake Road, Quilcene Good morning, Sally. Can you or someone at the county provide us an update on where things are in the process for this zoning and building permit request for Sprint "Tarboo Lake' please? Thank you. r t z x Aileen .'' Y i 4 Aileen Zavales I Lynx Consulting, Inc. ; a, 1,�� a .• 4 h � t3 , 17311 135th Ave NE, Suite A-100,Woodinville, WA 98072 Cell 206-972-1368 f� 6--j 972-13/68 l Fax 425-354-3277 l azavales @lynxconsulting.org •: ;, rz» r 3 r; , ° L 1 y'e >Cfi a r s4 y¢a�it;�iyt j Connect to the Future • 1 WREN CONSTRUCTION INC Page 1 of 3 • • CoWashington State Department of Labor & industries WREN CONSTRUCTION INC Owner or tradesperson 1410 80TH ST SW STE A HAGY, DANIEL ERIK EVERETT, WA 98203 425-252-1282 Principals SNOHOMISH County HAGY, DANIEL ERIK, PRESIDENT BONSEN, RANDY (End: 02/28/2012) BROIHIER, JEFF, AGENT (End: 02/28/2012) Doing business as WREN CONSTRUCTION INC WA UBI No. Business type 601 925 797 Corporation License Verify the contractor's active registration/license/certification (depending on trade) and any past violations. Construction Contractor Active. Meets current requirements. License specialties GENERAL License no. WRENCI*013B6 Effective—expiration 01/2611999—01/26/2016 Bond DEVELOPERS SURETY & INDEM CO $12,000.00 Bond account no. 521522C Received by L&I Effective date 01/03/2002 01/26/2002 Expiration date Until Canceled Insurance Alaska National Insurance Co $1,000,000.00 Policy no. 14EPS08393 Received by L&I Effective date 04129/2014 05/01/2014 https://secure.lni.wa.gov/verify/Detail.aspx?UBI=601925797&LIC=WRENCI*013B6&SAW= 9/29/2014 -N ti r J I Co m FQ EA N''' h f! O II.II m 00 '2 w 0 H 0 o VV r Z / / / i 0 / / I SISTINE. SR'-O" LMISIING SPRINI / \ I / ENCED WIRELESS / COIAFO\IND FENCED EASE AREA S ,., "d f x r A 1 f.l 0 X403 K • x 3 is 1 / n T / �.. , 2 \ / I I `"41 I o � t r / z •o / / Z' • 0 E r„ i _ 1�: p 1 D �J / T fl I i ,■k / / Al \ r x oc' �` 1 I , I oP I % A I r Ant I r N or C T n 0 / Y q Ofivo Fri I ak 0 1 m / o T J ea _(f) z W _ k"g —I / p o C=/ S ON CC i 3 z..... Z C z---1 E gV" Z 0 "-1 1aoo r"A g o'A� " %-71 1311 p El > CO m' . ti „.,..„.7° z D W W o u�i m.�-�i$mr�`Vi Fu, ' n > > r70'�� f TC �' b um �• U 1 CD p W Er4yRAono I u, n m A I 0 X1`2 R. 1O ^^ • X y OAN-pyY !.1 !.1 D y u / n F =0 o�� m m m a 3'\ ♦ ...6N y o oe z rDOOA a m° a 1,...21<') `f �, I 1i Cn g r� I gg_o$= aF ,i N m Xi • Land Use Permit Review Routing � Re: GI( tom; &L t)(y 3 ( i3 Project Planner j./ ) . ne- dfs P(ci4 ('heel Sim.! Planning Team Leader Review le4,-F-- U p- , ,,,i-} e,J, cOyTh UDC Administrator bt e), Up-Front Reviewer (117,4 cj�� n2."` A vim, _ 7 (2 S"' s ' ( ,ae Return To: nC'a•�P��°� ( r Type Amount AI By: Date: Receipt: Approved/Date Permit $168.00 SRE 09/03/14 151503 Plan Check $109.20 SRE 09/03/14 151503 State Building Code $4.50 SRE 09/03/14 151503 Total: $281.70 \\tidemark\data\forms\F_BLD_App_Bld.rpt 9/3/2014 • 0 V LY N X August 14, 2014 I III SEP - 3 2014 , i �I Jefferson County j 1j Department of Community Development JcicolINTY i I- 621 Sheridan Street —_QFFr of ro^dr 'I--- .._- T Port Townsend, WA 98368 RE: Sprint SE33XC013 Tarboo Lake/ATC82962 at 2755 Tarboo Lake Road, Quilcene, Parcel No. 801181001, Antenna Modification, Request for Zoning Approval and Building Permit Dear DCD: On behalf of Sprint, Lynx Consulting is submitting to Jefferson County a request for zoning and building permit approval, for modifications to an existing wireless facility located at 2755 Tarboo Lake Road, Quilcene. Specifically, Sprint proposes to modify the existing wireless facility with the addition of three panel antennas, three RRHs, six cylinders and one filter. The existing facility is a 177'0"tall self- support/lattice tower. Sprint presently has an existing antenna mount with three panel antennas; the rad center of antennas is 167'0"AGL. The new antennas will be mounted on the existing mount at the same height as the existing. There are no changes at the ground level or any site disturbance. Enclosed please find the following: • One Master Permit Application • Three sets of construction drawings (11 x 17")prepared by Lynx Consulting • Three Structural Analysis Report dated 8/14/2014 prepared by ATC supporting the proposed antenna modification • Check in the amount of$528.70 (Land Use fee of$228 and the balance is based upon the project's valuation of$10,000 per Mary of your office -building permit fee is $300.70) If you have any questions or need additional information in order to deem this application complete please call me at 20 6 972 1368; my email is Azavales@u,lynxconsulting.org. Thank you for your consideration. Areti, 1n vii Lynx Con' g Enclosures 1 i P a g e 17311 135th Avenue NE, Suite A-100, Woodinville, WA 98072 1y - (4SON `"G. JEFFEWN COUNTY ■ F C E I V 1 K DEPARTMENT OF COMMUNI 110 l'',-�-• - � 621 Sheridan Street I Port Townsend,WA 98368 I Web:www.co.j: "n wa.us/communi develo me as y1 Novo Tel:360.379.4450 I Fax:360.379.4451 Email:dcd• *..efferson. N sl SEP - 3 2014 Building Permits &Inspections Development Consistency Review I Long Range Planning I Wate . -r ` - : ea ;. ra r e': :r Master Permit Application M DEPT OF COMMUNITY DEVELOPMENT Project Description(include separate sheets as necessary): Sprint proposes to modify its antenna equipment on the existing telecommunications tower.The over-all height of the tower will not increase. Tax Parcel Number: 801181001 Property Size: (� j acre square feet) Site Address and/or Directions to Property:2755 Tarboo Lake Rd,Quilcene,WA 98376 Q2°l(/2 TOWFR nPPRATOP r 33YC013 [ (s)of Record: A%Y1!/rl'Can Tyr 4 rttre Telephone: 7 B)-q 214'-1-/ Q Fax: email: Mailing Address: f b tr(eld(rl7'2/ Woj ylidb cl fn r MA- .0 IT 0) Applicant/Agent(if different from owner): Lynx Cnnsr dtin0,fri t,-b 'Z , do Sprint Telephone gob Fax: 4?S 35'i 39-71 email:f�,2' Vci ICS '') Mailing Address: 17311 135th Ave NE,Suite A-100,Woodinville,WA 98072 What kind of Permit?(Check each box that applies ❑ Lot or Road Segregation Building ❑Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) ❑Single Family ❑ Garage Attached/Detached ❑Conditional Use[C(a), C(d),or C]** ❑ Manufactured Home ❑ Modular ❑ Discretionary"D"or Unnamed Use Classification • Commercial* ❑Special Use(Essential Public Facilities)** ❑ Change of Use ❑ Boundary Line Adjustment ❑ Address ❑ Road Approach ❑ Short Plat** ❑Home Business ❑ Cottage Industry ❑ Binding Site Plan'" ❑Propane ❑ Long Plat** ❑ Sign ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes" Use Consistency Analysis ❑ Plat Vacation/Alteration** ❑ Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions'"` ❑ Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development*" ❑Temporary Use ❑Shoreline Management Variance IR Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land Use District Map Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment *May require a Pre-Application Conference ❑Tree Vegetation Request **Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, if known: L nX COr1SUl DESIGNATION OF AGENT I hereby designate y to act as my gent in matters relating to this application for permit(s). TOWER OPERATOR /�7 OWNER I( � NER SIGNATURE By: ( Date: ll 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 its 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 r ui ed later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap that she wa t i l 1. tce. Signature: Date: - 1 q`j Lj The action or actions Applic 11 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 ou re in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transf ble sponsibili or adhering to and complying with the ESA. The Applicant has read this discliiimer and signs a d dates it below. p Signature: Date: itt / 07/24/2013 �vsoN ro �4 C, JEFFERSON COUNTY W DEPARTMENT OF Ct7MM,�l (� � -' !� T by "02 621 Sheridan Street�Port Townsend,WA 98368 I Web: uu e'"-rson.wra.us co- -u toraga.r t Sr/d N�,4 Tel:360.379.4450 Fax:3611379.4451 j Email:dcd.,..-;-- .nswa.us 1 i t SEP — 3 2014 Building Permits&Inspections l Development Consistency Review I Long Range Planninajjt4 tershed Stewardship Hesource„• ,er Master Permit Application Project Description(include separate sheets as necessary): ; i''r' n^.rq`hiT Sprint proposes to modify its antenna equipment on the existing telecommunications tower.The over-all height of the tower will not Increase. Tax Parcel Number. 801 181001 Property Size: ({acre square feet) 2755 Tarboo Lake Rd,Quiicene,WA 98376 Site Address and/or Directions to Property. rP�2`TUZ TOW ER OPER ATOR 33Xc o 1 3 of Record:_A►'y) 'cap •Tdweir s r tre 'L417i?'Yr-- on Telephone: 7 --,7 2-4,—1/5 3 0 7i Fax. email: Mailing Address: lb frjvA/aC/Zt7a(- r yNObilI-di, m/} 0 /$o) Applicant/Agent(if different from owner): Lynx C nnsillting,AtiVta•• '�, rJn Sprint Telephone Vitt" en -- ). 42 Fax: LAS .3S4-i 2.71 email- Zit:C�JC& `') 1y. Mailing Address: 17311 135th Ave NE,Suite A-100,Woodinville,WA 98072 ( r"13f1) 3.+G What kind of Permit?(Check each box that applies 0 Lot or Road Segregation RIBuiiding 0 Critical Areas Stewardship Plan O Demolition Permit 0 Variance(Minor, Major or Reasonable Economic Use) 0 Single Family 0 Garage Attached/Detached 0 Conditional Use IC(a),C(d),or CI** O Manufactured Home ❑ Modular 0 Discretionary"0"or Unnamed Use Classification ZI Commercial* 0 Special Use(Essential Public Facilities)** O Change of Use 0 Boundary Line Adjustment O Address 0 Road Approach 0 Short Plat** 0 Home Business 0 Cottage Industry 0 Binding Site Plan** ❑Propane 0 Long Plat** 0 Sign 0 Planned Rural Residential Development(PRRD)/Amendments** 0 Allowed°Yes"Use Consistency Analysis 0 Plat Vacation/Alteration** 0 Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions** 0 Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Substantial Development** 0 Temporary Use 0 Shoreline Management Variance G Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land Use District Map Amendment 0 Forest Practices Act/Release of Six-Year Moratorium 0 Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference 0 Tree Vegetation Request **Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, if known: Lynx Consul DESIGNATION OF AGENT nx I hereby designate Y to act as my agent in matters relating to this application for permit(s). TOWER OPERATOR ,,f/A f 1�f f 7 OWNER SIGNATURE By: / •t i.�% Date: i i f 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 its 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 attorneys 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 r_.ui ed later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap. that „ she wants .n r otice. (�j Signature: ( ,� •� Date: It) The action or actions Applic ti 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 spades regarding your action(s)even if ou re in compliance with the Jefferson County development code. The Applicant acknowledges that he,she or it holds individual and nomtranste ble ponsibili or adhering to and complying with the ESA. The Applicant has read this disc imer and signs a dales it below. Signature: ` :t, - _ -- Date: ri i ^ /L% • • • 9- BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of Me parcel referenced herein,that they are not licensed contractors and that they will be asiiming the responsibility of the General Contractor for the proposed project, Signatun Date: T -�q GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: } L, M9pE� F '-"t 1 Fax: 7-73D...... (CLC ) t ( ) MAILING ADDRESS: I 1 EMAIL: {j i CONTRACTOR'S LICENSE \i' i p FWAIN ^ f,l NUMBER: H , SFr 2014 IIL i, , NUMBER Fax: ARCHITECT/ENGINEER: j 1,, PHONE ( ) ( ) MAILING ADDRESS: JL"EMAIL J',n_Y .. Project Type: Frame Type: Bathrooms: ShoPetitie:—Type of Sewage Disposal: 3 New I.7 Wood Existing: p.) lk- LI Sewer El Addition Steel Proposed: Bank 0 Community System x Alteration/Remodel L Concrete Total: Heighfly 0 Individual System j u Repair Masonry /�/r'' SEP Permit# NWT- : Demolition Bedrooms: Other: Water Supply: iro= n Existing: Setback: Li Private well Two Party Typepf Heat: Proposed: ❑ Public ,J /- (( Total: Name of System: 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 Qncludes owners,tenants,employees,etc), Current Proposed V--IBC Occupancy: - IBC Type of construction: 'It J tA- Will you have Food Service? Yes If this is a Propane Tank and/or Appliance Installation permit,ma all items below that apply: i Underground Tank I Above ground Tank Size of Propane Tank: ti Heat Stove i Cook Stove I Woodstove i Fireplace Insert I Hot Water Tank i Pellet Stove I 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 lines,buildings and septic system components, including the reserve area. I � '' a a , " t . 's M1 ° Square Footage Current Proposed For y� �Y „ _ Amount *Rrlfon max- , ,, Main Floor Heated EH Bld App Review: 21.4 Floor Heated -...-4,--,r--.:'_.' Consistency Review Other Heated Base fee: 4: Icob Mezzanine a , . ' Additional Section: Heated Basement ", Plan Check fee: 1P C1 . Z° Unheated Basement -_ r State Surcharge fee: Other Unheated Pot Water Review fee: _I't.,`, Garage/Carport =? SUBTOTAL -T/ Decks 911/Rd Approach fee: w T" Other TOTAL: $ �--aq- .. �friy/VNt in 6A C1 +,,, ^ , Receipt Number. I Q ti, °e Cash/Check Number: 6 I ESTIMATED COST(REQUIRED) Date: /y 3/ I `, I .Fair market value of all labor and,nd materials foundation to finish 10 l- ..-- Initials: , GAPernutCentcr1###FORMS###\Dilll FORMS\Master Permit AppUcaaan 5-29-08.doc • • 6\ [tZCrEEN ' -Th oN °� JEFFERSON COUNTY L) f W `Q bl, DEPARTMENT OF COMMUNITY OEVELOPM NT SEP — 3 2014 . I 621 Sheridan Street • Port Townsend • Washington 98s68I I i' O O� 360/379-4450 • 360/379-4451 Fax JEFFERSON L'OUI TY http://www.co.jefferson.wa.us/commdevelopment/ I__, DEPT OF COM%",UGIITY DEVELOPMENT Stormwater Calculation Worksheet } �" MLA PROJECT/APPLICANT NAME: AI�JSy-e Zi j4 d , t77\A ey -K cp-il DETERMINING STORMWATER MANAGEMENT REQUIREMENTS:This stormwater calculation worksheet should be completed first to classify the proposal as°small'"medium,"orlarge." The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan,if required. / acre PARCEL SIZE(I.E.,SITE) Size of parch(15 5 (, An acre contains 43,560 square feel. Multiply the acreage by this figure. Size of parcel in square feet :94.1;),, 9i-7. 7C q/ft Land-disturbing activity is any activity that results in movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing, grading, filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species, other than noxious weeds,that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir,western hemlock,western red cedar, alder,big-leaf maple,and vine maple;shrubs such as willow,elderberry,satmonberry, and salal; herbaceous plants such as sword fern, foam flower,and fireweed. LAND DISTURBING ACTIVITY,CONVERSION OF NATIVE VEGETATION,AND VOLUME OF CUT/FILL Calculate the total area to be cleared,graded,filled, Answer the following two questions related to excavated, and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Does the project convert'/.acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? e Drainfeld,septic tank,etc. sq/ft Circle: Yes la Well,utilities,etc. sq/ft Does the project convert 2%:acres or more of y native vegetation to pasture?"�' Driveway, parking, roads,etc. 4.—"}--- t—.! sq/ft l/ Circle: Yes Lawn,landscaping,etc. sq/ft Other compacted surface, etc. t:y �) sq/ft Indicate Total Volumes of�Proposed: Total Land Disturbance IV" "`•' sq/ft Cut �vW Fill fV bt)"t'(cu/yd) [over] wormwatar Gale worksheet-REV 2/200009 1 1110 E I sFP - 9014 1 1 Impervious surface Is a hard surface that either prevents or retards the entry of water into the soll,mantle as under natural •nditions prior to development. A hard surface area which causes water to run off the surface in greater gUantities'or at art increased r- a of flow from the flow present under natural conditions prior to development. Common impervious surfaces include,but are,not limited to roof tops, walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving,gravel roads; packed aaltllen Ihaterials, and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. STORMWATER CALULATIONS–IMPERVIOUS SURFACE NEW EXISTING Cltij `.JA.. Structures(all roof area) sq/ft Structures (all roof area) `f" sq/ft Sidewalks CB sq/ft Sidewalks sq/ft Patios CJ sq/ft Patios sq/ft Solid Decks sq/ft Solid Decks sq/ft (without infiltration below) p� (without infiltration below) Driveway,parking,roads,etcrt' sq/ft Driveway, parking, roads,etc sq/ft Other Y 't 7-X sq/ft Other sq/ft Total New sq/ft Total Existing sgtft TOTAL NEW+TOTAL EXISTING' C/ sq/ft This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v.REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: °/a Does the site have 35%or more of existing impervious surface? Circle: Yes FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture, the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet. Proponents of"medium" projects—those that must meet only Minimum Requirements #1 through #5—and for "large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwater Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation Worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owner of the affected property. j (LANDOWNER OR AUT RI D REPRESENTATIVE SIGNATURE) (DATE)" A / ' v , a �+ fiF`,":4 h rT ex a 7 a tx, a r s . j w ,'' ' A-40e ' ' *. a s ii • f rs. y741,- Il! stormwaler talc worksheet-REV.22012008 2 MOL OF OFF;Cf,L! ' CJRDS REQUEST OF 11E0E0V 19S4 AL6 29 PN 12: 58 FFERRSkOY N:CGJ ? AY TOR I , SEP — 3 2014 bt 1 i J Weri-•Mnliner I JEFFERSON COUNTY DEPT.OF COMMUNITY Y DEVELOPMENT Filed for reoerd at request of ? • .1 J 1 and when recorded return tar 1"' V 5 1299r ReWeetor Group, [nt., AMC: net !state and Construction Dept. 3150 lalst Are. 9a P.O. Bea 91211 Sellers*, Sea. 94001-9211 MEMORANDUM OF OPTION AND LEASE LEASE AGREEMENT• This Memorandum dated this / '," day of /EtI'.GFI , 1994, by and between Pope Resources, a Delaware Limited Partnership, (hereinafter "Lessor") and San Juan Cellular Limited Partnership, P.O. Box 91211; Bellevue, Washington 98009-9211 (hereinafter "Lessee") , is a record of that Option and Lease Agreement (hereinafter "Agreement") between Lessor and Lessee dated ftP_Ct{ 7f lck , which Agreement includes in part the following terms: 1. Leased Premises. The Agreement pertains to real property which is described in Exhibit "A" (hereinafter "Property") , which is attached hereto and incorporated herein by this reference. 2. Term of Agreement and Options to Extend. The initial term of the Agreement is for a five-year (5) period commencing on the date the Option is exercised by Lessee. Lessee has options to extend the Agreement term for four consecutive five-year (5) periods. Lessee may, under certain conditions, elect to further extend the term thereof. 3. Successors and Assigns. The terms, covenants and provisions of the Agreement extend to and are binding upon the respective executors, administrators, heirs, successors and assigns of Lessor and Lessee. 4. Ratification of Lease. The parties by this Memorandum intend to record a reference to the Agreement and do hereby ratify and confirm all of the terms and conditions of the Agreement and do hereby declare that the real property described in Exhibit "A" attached hereto is in all respects subject to all of the applicable provisions contained in the Agreement. 1V i O EAT EsTA q SALES CO 1 li`:: i 1:,-:CASURER -.411 III • LESSOR: Pope Resources, a Delaware Limited Partnership, by Pope MGP, Inc. , its Managing General Partner By: - Y Its: Date: 317 I c1 / LESSEE: San Juan Cellular Limited Partnership, by U S WEST NewVector Group, Inc. , as it neral Partner By: Its: Director Field Operations Date: 4/1-2 -`79 %asoo2 9-1-41 2 1 ! I • STATE OF WASHINGT� ) .4._..W.�..a. •.v-yV.,yuvv • )ss. COUNTY OF KING ) On thisDo : not , 1994, before me personally appeared 'V� , to me known to be the g_,__p__of U S W ST NewVector Group, Inc. , the general partner or San Juan Cellular Limited Partnership, the partnership that executed the within and foregoing instrument, and acknowledged said instrument to be the free and voluntary act and deed of said partnership, for the us,�� and purposes therein mentioned, and on oath stated that was authorized to execute said instrument and that the seal affixed, if any, is the seal of said partnership. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal th, ,,,, av,, and year first able written. Ca ' :::5----:--) �ss• „qSA REG�y�% Notar lic in and for the .� NOTARY '61; , St a of Wa h ngtor}, . : -+r-. ; residing at lA • l u„= 'o : - My appointment a ires: ►�`dc1 ``i G ?-y�''Oq,� ,e3°•'.�o,.' Type or print pfigtary's Name: `f,, p•"29"'.`�C'.`� CORPORATE ACKNOWLEDGMENT STATE OF Washington ) )SS. COUNTY OF Kitsap ) On this '7'h• day, of 47-z1/•-•("'i r . , 1994, before me personally appeared C— 7-/ —^/19,-/C r , to me known to be the (1 r-_■ of Pope MGP, Inc. , the corporation that executed the within and foregoing instrument as General Partner of Pope Resources, a Delaware Limited Partnership, and acknowledged said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that `'e was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my ..-6-0.6E1cial seal the day and year first above written. I. v'��` iqublic in and for the „ 510 te; of/ Washia�g on --------- i re�sidl.nt at _ › (.-rn�- I T-� rr�- 1 Lo.. ,- a� intment expires: - i-y%4-' �'_ I� L/ I� (l 4i�y O1T E'V li Print Notary's Name: [} I 1 VH�r !„A�4 4 she,— / ,l ' 1��`;:�� S E P - 3 2014 . L/1 I -- art c• rr.7 • f�1-Ir `� n/7 Wal Gardiner LiI V i 1 SLP - 3 2014 1 Exhibit "A" JEFFERSON COUfdiY ega1 Description '- n;C^: ni nr :I n'TENr A portion of the NW 1/4 of Section 18, Township 28 North, Range 1 West, consisting of a parcel containing 3 ,000 square feet. , full legal description of the Property will be inserted upon recipt of the survey. - -.---.--,,.- •P1lC.ie*1 ewfo-1 1_ ,,.,.,,,.,,4...,,,, o,,°� Access via existing M(.....ia..s u+.r logging road to SR 104 SEC 18 TWP28N ,11E \ '� 1 ` 1. I] RGE 1W 1 1 In a MI WAG)\ (ICS AO a--,ce.0.L SS t Ot 1 C K 4.(Y MOW-LESS tai 1) GV4 . ` 1 1 'r \ l 1 1 V 1 I 1 1 LEASED AREA # \ 1 50' x 60' / VA 1 1 1 1 1 1 1 1 I 1 1 r° Y s 1 Jelleleel F�t'Y17 owe MO°p �! i 1 1 41 OE SEC”CtILESS C. t111 1 Y 9/V)SA115( CM a �� ■.•C 1125a w LACE) I� Qi \ 1 n ` 604.1 11 i 11 SCALE: 5 1 1 1_ 400' 1 1 1 1 1 1 ■ 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1_oS 1 1 GO'S II N. a 4 SI..H. 1 I IJ •0 1• 11 w...141. 11[19 Islet .n. 1 . a9_2.1_11 —JEFFERSON COUNTY ASSESSOR— 1 ammo • • FM RECORDING REQUESTED BY AND WHEN RECORDED RETURN TO:SULLIVAN WORCESTER LLP One Post Office Square Boston,MA 02109 Attn: Dianne M. Cosman,Paralegal ORIGINAL AL (Space above this line for Recorder's Use) - --11" MORANDUM OF SUBIB E ASE ,r This MEMORAN UUM OF SUBLEASE, made and enterdd into as of this 15`day of May, 2001 by and between SEATTLE SMSA LIMITED PARTNERSHIP, a Delaware limited partnership ("Sublessor")* and American Tower Delaware Corporation. a Delaware corporation ("Sublessee")**. 1. Pursuant to Site Designation Supplement number 522,effective May 1,2001,which is governed by the terms and conditions of that certain Sublease entered into between Sublessor,Sublessee and other parties identified therein on January 19,2000 which is incorporated herein by this reference, Sublessor subleased to Sublessee,and Sublessee subleased from Sublessor,the Subleased Property(defined below). The Commencement Date for the Site Designation Supplement is May 1,2001. Notices with respect to the Site Designation Supplement shall be,in addition to the notice address in the Sublease,directed to: Verizon Wireless(VAW)LLC 180 Washington Valley Road Bedminster,New Jersey 07921 2. The Subleased Property subleased to Sublessee under the Site Designation Supplement is a portion of the real property commonly known as WA!GARDINER-522 and more specifically described in Schedule 1 attached hereto. • 3. In the event of any conflict between this Memorandum of Sublease and the Sublease(and Site Designation Supplement),the terms of the Sublease(and Site Designation Supplement)shall control. *Address of Sublessor: **Address of Sublessee: c/o Verizon Wireless(VAW) LLC c/o American Towers, Inc. 180 Washington Valley Road 116 Huntington Ave., 1 lth Floor Bedminster,New Jersey 07921 Boston, MA 02116 Project Vertical Number-522 IN WITNESS WHEREOF, Sublessor and Sublessee have duly executed this Memorandum of Sublease as of the day and year above written. SUBLESSOR: SUBLESSEE: SEATTLE SMSA LIMITED PARTNERSHIP, AMERICAN TOWER DELAWARE a Delaware limited partnership, d/b/a Verizon CORPORATION, a Delaware corporation Wireless By: VERIZON WIRELESTIV ) LLC, ��'�✓ �"U a Delaware limited liability company, By: its general partner Jonathan R. Black Via President By: CELLCO PARTNERSHIP, a Delaware Partnership, its sole member By: LLL/L/t t Z L "� 7 /.Lk- Bernadette Faiella Acting Executive Vice President and CTO Date: "41/ Al 0 I Date: 9 I 1'4 f' J Tax ID No.: Tax ID No. 3481371 • ECEOVEn 11 i SEP — S 2n14 1I I! I -6(i‘: Y ri r OF r -rnTY rVr .. PV 522 • • STATE OF NEW JERSEY Somerset County • On this ‘24.,/�1 .:: o `�`' '' 'A-Le .: . 2001, before me, 49 r[4 / -A: /et �.,(�` a'1r4jai 'Public in and for said Cody and State,personally appeared Bernadette Faiella, Acting Executive Vice President and CTO of CELLCO PARTNERSHIP„ who acknowledged that he/she did sign the foregoing instrument and that the same was her free act and deed as such Acting Executive Vice President and CEO and the free act and deed of CELLCO PARTNERSHIP. WITNESS my hand and seal this ,�1"7- day of (/._,n-‘), : , 2001. (Print Name) 4 A g 7-T ,vim/-} S e-.-Z_ Notary Public My Commission Expires: ANNETTE VAN TASSEL Notary Public of New Jerewp Mir Ceaxe oee Expires Marsh OS,2004 1 I i' i , 1 fl SEP - 3 2014 +j I / Ju rcRSCN COUNTY f ^.:, g riro;rfr OEyFLODPnFNT PV 522 • • CORPORATE ACKNOWLEDGEMENT COMMONWEALTH OF MASSACHUSETTS) ) ss COUNTY OF SUFFOL` r On this day of ( , 2001, before me,the undersigned, a Notary Public in and for the Commonwealth of Massachusetts,duly commissioned and sworn, personally appeared Jonathan R. Black, to me known to be the Vice President of American Tower Delaware Corporation, a Delaware corporation, the corporation that executed the foregoing instrument and acknowledged the said instrument to be the free and voluntary act and deed of said corporation for the uses and purposes therein mentioned, and on oath stated that he is authorized to execute the said instrument. WITNESS my hand and official seal hereto affixed the day and year first above written. (Print Name) t"."-(M eY r A. 'LW" <-, Notary Public in and for the Commonwealth of Massachusetts My commission expires: !'1;'� {�1, 1 S EP - 3 2014 ,jj 'J is PV 522 JEFFERSON COUNTY CFPT Of COMMUPIEN rAyEO°A9ENT_,_ • • SITE DESIGNATION SUPPLEMENT NUMBER 522 This Site Designation Supplement is governed by the terms and conditions of that certain Sublease entered into between AirTouch Communications,Inc., American Tower Delaware Corporation and the other parties named therein, on January 19, 2000,which is incorporated herein by this reference. The Commencement Date for this Site Designation Supplement is May 1, 2001. This Site Desigi ion.& ple"inent relates to "Proje 'ertical Site Number"522. Schedule 1 ("Legal Description of Sublessor's Property") and Schedule 2 ("Description of Subleased Property")attached hereto are hereby incorporated into this Site Designation Supplement by this reference. Concurrent herewith, a"Memorandum of Sublease"is being prepared and executed by "Sublessor"and"Sublessee"(each as defined in the Memorandum of Sublease),which Memorandum of Sublease corresponds with this Site Designation Supplement. This Site Designation Supplement shall be deemed to be duly executed and approved by Sublessor and Sublessee upon execution by such parties of the corresponding Memorandum of Sublease. vEio \ �� -3V\ SEP - 32014 LOPT JEFFERSON COUNTY DEPT.OF COMMUNITY PV No. 522 • • • Schedule 1 Page of _ LEGAL DESCRIPTION OF SUBLESSORS PROPERTY Street address:1696 STATE ROUTE 104 City: _. . �— State: Washington ; '"' `G�4" Zip: All that real property located in the State of Washington,County of JEFFERSON,described as follows: The Sublessor's property of which the Subleased Property is a part is legally described as follows: ON THE FOLLOWING PAGE: SITE ID: See Section 3 of Memorandum of Sublease GROUND LESSOR'S PROPERTY: See 'Property Legal Description" DESCRIPTION OF SUBLESSOR'S PROPERTY: See "Premises Description' if available Jt SEP - 3 2014 JEFFERS0^dCOUNTY WFPT.OF COMMUNITY DE'Ed Project Vertical Number: 522 • • - SCHEDULE 1 j , C5 c 1 0 `' f I1 Page 2 of -LA . I L/ � II I I n; ' SEP - 3 2G14 ii I! (1f_PT.OF ni g?!UPgl 1 F gi � rr Wal Gardiner Exhibit "A" Legal Description �+vw�wc•a - _ A portion of the NW 1/4 of Section 18, Township 28 North, Range 1 West, consisting of a parcel containing 3,000 square feet. A full legal description of the Property will be inserted upon receipt of the survey; Access via existing •- logging road to SR 104 SEC 18 u r n-._." •s... 1WP28N ` '1 •; r RGE 1W t 101 ; 1 ti t w vva�Zo.u"w 11 °O r 1 t ■ \ 1 t rureoo 1 1 1. • 1 IAKF ■ ' LEASED AREA Loi 1 50' x 6D' GOJ'l '1'-!1‘■ vt 1 1 1 1 i 1 I 1 1 1 411110,1'1.[ f L. 1 9a irrl u% f[M.11[A •o1u 1 11 1.4`9 uuC Ian. 1 1 IK ssr.rl.g1 �,{ 1,01 ;IZ i I 40 1 1, • 1 1 1 1 1 �1 1 1 ■ 1 1 1 1 • 1 i 01 i 1 G0'1i 1 i 4 'N 1 1 1 1 Mel 1 1 wr M1111046 i • • 1 n�,a -- nn ~11•• or-w-.y voi 512 > 96 um 5� COUNTY ASSESSOR Pv-..._ 5 Z2 SCHEDULE 1 1= 7 �`�71 Page j of nn --- IJ n i SEP 14 ' BAIMA& HOLMBERG INC. ,r WA1 GARDINER EXHIBIT "B" -m.•"•c-,4 Legal Description SITE EASEMENT A 3,000 square foot site located in the Northwest Quarter of the Northwest Quarter of Section 18, Township 28 North, Range 1 West W.M. in Jefferson County, Washington. ACCESS EASEMENT A 20 foot wide strip of land, whose centerline follows the centerline of unnamed existing logging roads, as they exist in July, 1999, or as they may exist in the future, described as follows: Beginning at State Route 104 in Section 6, Township 28 North, Range 1 West W.M.; thence southerly thru the West half of Sections 6, 7, and 18 in said Township 28 North, Range 1 West W.M. to the Site Easement located in the Northwest Quarter of the Northwest Quarter of said Section 18. Length of Access Easement is approximately 1.2 road miles. .sla WPE HO..W..' 1 )'.� 41'aP ASyj 0. 31" aryl - f;y • au ,." nuwtro ,,per....._.. o� 5.17 1,4.0175 705881,GL-7.22.99 100 FRONT STREET SOUTH • ISSAQUAH •WASHINGTON • 980273817• (206)392-0250 • FAX(206)391.30:5 Pv# 5 22 • • SCHEDULE 1 Page LA of LA . • Exhibit "A-I" WA1 GARDINER SITE, ACCESS AND UTILITY EASEMENT A PORTION OF THE NORTHWEST QUARTER OF SECTION 18, TOWNSHIP 28 NORT(.MNGE 1 WEST, W.M., IN JEFFERSON COUNTY, WASHINGTON, DgSCRIBED AS FOLLOWS: . COMMENCING AT THE-NORTHWEST CORNER OF 'ti ID SECTION 18; THENCE S 39°06'03" E, A DISTANCE OF 2146.49 FEET TO THE TRUE POINT OF BEGINNING; THENCE S 00°00'00" W, A DISTANCE OF 60.00 FEET; THENCE N 90°00'00" E, A DISTANCE OF 50.00 FEET TO REFERENCE POINT "A"; • THENCE N 00°00'00' E. A DISTANCE OF 60.00 FEET; THENCE N 90°00'00" W, A DISTANCE OF 50.00 FEET TO THE TRUE POINT OF BEGINNING; TOGETHER WITH A 40 FOOT WIDE ACCESS AND UTILITY EASEMENT BEING 20 FEET ON EITHER SIDE OF THE FOLLOWING DESCRIBED CENTERLINE: BEGINNING AT SAID REFERENCE POINT "A"; THENCE S 00°46'25" E, A DISTANCE OF 133.24 FEET; THENCE S 33°35'48" E, A DISTANCE OF 84.81 FEET; THENCE S 10°53'25" E. A DISTANCE OF 137.23 FEET TO THE CENTERLINE OF AN UNNAMED EXISTING LOGGING ROAD; THENCE S 79°36'55" E. ALONG SAID UNNAMED ROAD, A DISTANCE OF 539.97 FEET; THENCE S 79°21'10" E, ALONG SAID UNNAMED ROAD, A DISTANCE OF 613.75 _FEET; THENCE S 79°57'05" E, ALONG SAID UNNAMED ROAD. A DISTANCE OF 1249.83 FEET, MORE OR LESS, TO THE INTERSECTION WITH THE TARBOO LAKE COUNTY ROAD AND THE TERMINUS OF THIS ACCESS AND UTILITY EASEMENT. 70588REV/12.16.94S�N't�t '" of �4 i' . ti uN ,41y unws (t 309( 100 FRONT STREET SOUTH • ISSAQUAH • WASHINGTON • 980273817 • (206)392-0250 • FAX(206)391-3055 PV# 522- 4111 • Schedule 2 • DESCRIPTION OF SUBLEASED PROPERTY The location of the Subleased Property within the Sublessor's property together with access, ingress,egress, easements and utilities are more particularly described or depicted as follows: A. Sublessor's Property described or depicted in Schedule 1 B.A 180 foot PIROD SSUP Tower and ground ring(if separate) C.All other physical improvements, .Y � emu , less and except in each inst -r (1) the Reserved Space thereof described in Schedule 3; (2) any Sublessor's Improvements and Communications Equipment on'such Site,and (3)Improvements of Existing Space Subtenants described as follows: Ant Ctr Name of Tenant Line(ftI Svc Provided Ant Type No Ant Land Area Reserved Space Simmons Cellular of WA 140 CELLULAR DISH 1 Simmons Cellular of WA 145 Cellular WHIP I Simmons Cellular of WA 155 Cellular WHIP 2 Sprint Spectrum L.P. 168 PCS Panel 9 r � clEOVIE jSEP - 3 23';4 L �� J JEFFERSON COUNTY DEPT.OF COMMUNITY DFVFLOPMENT II Project Vertical Number:522 • • • Schedule 3 RESERVED SPACE SUPPLEMENT [This is a replacement page; the actual Schedule 3 is on file"with American Tower- °` V y Delaware Corporation.] SEP - 3 2014 • !LJ1 JEFFERSON COUNTY DEPT.OF COMMUNITY DEVELOPMENT _ PV No. 522 • Sally Ellis From: Aileen Zavales [Azavales @lynxconsulting.org] Sent: Thursday, August 28, 2014 11:21 AM To: Sally Ellis Subject: Master Permit Application for 2755 Taboo Lake- missing page two Attachments: SE33XC013_82962 Master Permit App.pdf Hi Sally, and here is complete application for other, also a valuation of$10,000 and contractor TBD. Thanks again for your help and patience. Aileen WIEAVF1.1 Aileen Zavales I Lynx Consulting, Inc. U) 17311 135th Ave NE,Suite A-100,Woodinville,WA 98072 lI Cell 206-972-1368 I Fax 425-354-3277 I azavales @lynxconsulting.org i i SEP — 3 2014 ;a NI Connect to the Future L � 11 JEFFERSON COUNTY _ OEPT.01 COMMUNITY ITY Cn/ I`PMENT 1 • ! Sally Ellis From: Sally Ellis Sent: Monday, August 25, 2014 8:25 AM To: Sally Ellis; Azavales @lynxconsulting.org Subject: RE: 2 new permit with Jefferson County Attachments: Masterapp.pdf Dear Aileen Please confirm that you have received the below email and the voicemail that I left with you office last week. I must have the second page of the Master Permit application filled out and returned to me in order to start the process of these two new permit. Please email these back to me as soon as possible- If I do not hear from you by the end of today- I will have no choice but to mail the incomplete applications back to your office. Thank you Sally L Ellis Jefferson County Community Development Permit Technician 621 Sheridan St. Port Townsend,WA 98368 360-379-4452 sellis @co.iefferson.wa.us From: Sally Ellis Sent: Thursday, August 21, 2014 8:51 AM To: 'Azavales @kynxconsulting.org' Subject: 2 new permit with Jefferson County Dear Aileen We received two new permit for your company for Sprint, Please note these applications are not complete- We need to have the second page filled out. We need to know who the contractor is- We need the Market valve cost of the project. This is where I also receipt the fees. I cannot start the process of these permit until I have that information. If you have any questions and if possible fill this information out and email them back to me. Thank you 1 Sally L Ellis S Jefferson County Community Development Permit Technician 621 Sheridan St. Port Townsend,WA 98368 360-379-4452 sellis@co.jefferson.wa.us 2 alp Front Parcel Review • �/Y- 31� Parcel 801181001 Printed: September 4, 2014 POPE RESOURCES Site Address(es): C/O OLYMPIC RESOURCE MGMT 1696 HIGHWAY 104 QUILCENE, WA 98376 19950 7TH AVE NE#200 2747 TARBOO LAKE RD QUILCENE, WA 98376 POULSBO, WA 98370 2755 TARBOO LAKE RD QUILCENE, WA 98376 Parcel Number: 801181001 S-T-R: 18-28N-1W Total Acreage 635 Legal Description S18 T28 R1W ALL OF SECTION(LESS TAX 1 &R/W) Land Use: 8800 S/EASE Flood District: Fire District: 0 Planning Area: 10 Flood Map(FIRM) Panel No: School District 48 Zoning:C o.,iuMti� COMP PLAN DESIGNATION: COMMUNITY PLAN: UGA: UGA Trans [ ] Plot plan states "property line" [ ] Assessor's Map (Property lines on submitted plot plan must match the property lines as identified on the Assessor's 1/4 map) [ ] Legal Access to Property NO [ ] Parcel Tags or Scanned Documents YES _ND /4;, s eel/ 70e r�r-yznrs [ ] ESA's: Special Reports Nearby YES t�D- [ ] Designated Ag YES N)--- [ ] Shoreline Designation: YES .1,1a- [ ] Shoreline Slope Stability: YES O Stream Type:YES � FWHCA: YES 1)1 C.\ Wetlands: YES Rare Plants:YES >D- Seismic: YES N9 Landslide: YES JD- Flood: YES 1 ^ Erosion: YES 4Ni:1- Aquifer Recharge Area:YES ../la-- SIPZ: „true At Risk High Risk Coastal CMZ: High Risk Moderate Risk Disconnected CMZ Stormwater site plan submitted: Yes.- [ ] Forest Lands: NO Adjoining Forest Lands: // Commercial/ Rural/ Inholding [ ] Mineral Lands: YES 2 [ ] Agricultural Lands: YES !ILL-- [ ] Archaeology: YES [ ] No Shooting Zone: YES N¢_ [ ] Stormwater: New Impervious Surface Land Disturbing Activity ESA's Stormwater Req's:Min Req#2 Min Req#1 thru#5 Min Req#1 thru#10 Engineering [ ] Notice Provisions/Disclosure:Airport YES rroi MRL YES N3 Forest Lands es NO [ ] Landscaping Required: Yes N_/ [ ] Parking Spaces Required 2 Other 1 Building Height: 35' UBC Standard at)/4_ [ ] i ..[ ¢ "Impervious Surface coveraD e�rcentab e: � u Resource Lands&Public: 10% Rural Residential: 25% Rural IndustijPer UDC Sec 6.7 Rural Commercial: 60% Area of Building Coverage:60%in Rural Industrial Lands only [ ] Total Building (s) Size: -- RVC:20,000 SF CC: 5,000 SF NC: 7,500 SF GC: 10,000 SF All others:subject to septic&water constraints/None specified [ ] Setbacks: Front: 4A- Left Side: Right Side: Rear: Shoreline Setback: LSHA Setback: --- [ ] Road Classification: Road Approach: EXISTING NQ .LSD RAP [ ] SEPA Required: YES EX [ ] Flood Certificate: [ ] Existing Case(s) & Condition(s): Violations: Yes No [ ] Recorded Date of Subdivision: AFN Over 5yrs=UDC Plat Conditions: <5yrs=Plat Conditions on plat or Old Ordinance [ ] Lots/Require Declaration of Restrictive Covenant YES _ ubmitted: YES NQ [ ] UGA No Protest Agreement YES l�D--submitted: YES N .- [ ] Site Visit conducted YES ND- [ ] Require Final Zoning Approval YES >0- ] ADMIN: Setbacks—entered in Permit Plan case N/A YES New Parce s entered in Permit Plan N/A YES Spe ' eports Scanned N/A YES Title Notes Updated Parcel tags found for parcel 801181001 1.) 6yr Mor. on FPA2611840 application approved on 6/28111. Moratorium 06/29/2012 Non-Forest Permits expires 6/28/18. JCC18.20.160(5)(b) "Mandatory six year development moratorium. For six years after the date of the application the county shall deny any and all applications for permits and approvals, including building permits and subdivision approvals, relating to or for non forestry uses of land subject to the application. Parcel tags found for parcel 801181001 2.) WSRC Coaching - 2011-11-17, CZ 08/23/2013 Other Parcel tags found for parcel 801181001 3.) WSRC Coaching - 2011-02-14, CZ 09/03/2013 Other Parcel tags found for parcel 801181001 4.) WSRC Coaching - 2011-03-29, CZ 09/03/2013 Other Cases Associated with APN 801181001 Review Cases Name Type Status Planner BLD12-00347 SPRINT S Lisa Keller Application Received: 10/25/2012 Permit Issued/Case closed: 11/7/2012 Case Finaled: MODIFICATION TO EXIS I ING AN I ENNAS AND CABINETS BLD13-00219 POPE RESOURCES S Colleen Zmolek Application Received: 7/19/2013 Permit Issued/Case closed: 8/7/2013 Case Finaled: ONE NEW MICROWAVE ANTENNA WITH TWO LINES AND TWO-DUTTON-EXISTING WIRELESS TOWER BLD13-00258 SPRINT-GENERAL DYNAMICS F Zoe Ann Lamp Application Received: 8/21/2013 Permit Issued/Case closed: 9/13/2013 Case Finaled: 10/21/2013 ADDITION OF (1) MICROWAVE (MICROCELL) TO AN EXISTING CELL TOWER BLD14-00031 POPE RESOURCES I A David Wayne Johnson Application Received: 1/24/2014 Permit Issued/Case closed: 2/25/2014 Case Finaled: Remove 3 GSM antennas, add 6 LIE antennas, & 1 surge suppression unit. Add 1 GPS antenna, install new LTE equipment. \\tidemark\data\forms\R_Parcel_CRMLA.rpt 9/4/2014 Page 2 of 4 BLD14-00318 POPE RESOURCES P Tim Woolett Application Received: 9/3/2014 Per Issued/Case closed: Ca inaled: SPRINT PROPOSED 10 MODIFY ITS ANTENNA EQUIPMENT TELECOMMUNICATIONS TOWER. THE OVER ALL HEIGHT OF THE TOWER WILL NOT INCREASE. ADDIND ADDITION OF 3 PANEL ANTENNAS, 3 RRHS, 6 CYLINDERS AND 1 FILTER. THERE ARE NO CHANGES AT THE GROUND LEVEL OR ANY SITE DISTRUBANCE. BLD00-00360 VOICE STREAM WIRELESS F Application Received: 6/2/2000 Permit Issued/Case closed: 11/17/2000 Case Finaled: 2/20/2001 VOICE STREAM WIRELESS TOWER BLD95-00144 AT& T WIRELESS SERVICES F Application Received: 3/28/1995 Permit Issued/Case closed: 10/31/1995 Case Finaled: 3/26/1996 Cellular One Tower and Equipment Shelter FPA2605256 POPE RESOURCES F Application Received: 4/21/2003 Permit Issued/Case closed: 3/27/2003 Case Finaled: 4/21/2003 Aerial Chemical Application FPA2605260 POPE RESOURCES F Application Received: 4/21/2003 Permit Issued/Case closed: 3/28/2003 Case Finaled: 4/21/2003 Aerial Chemical Application FPA2605386 POPE RESOURCES F Application Received: 5/29/2003 Permit Issued/Case closed: 6/2/2003 Case Finaled: 6/6/2003 Aerial Chemical Application FPA2606697 POPE RESOURCES F Application Received: 4/22/2005 Permit Issued/Case closed: Case Finaled: 5/10/2005 TIMBER HARVEST 44 ac FPA2607144 POPE RESOURCES F Application Received: 8/17/2005 Permit Issued/Case closed: 8/28/2005 Case Finaled: 8/28/2005 44 acre harvest. FPA2609454 POPE RESOURCES F Application Received: 7/28/2008 Permit Issued/Case closed: 7/31/2008 Case Finaled: 8/5/2008 568 acre Aerial Chemical application FPA2609824 POPE RESOURCES F Application Received: 4/7/2009 Permit Issued/Case closed: 4/16/2009 Case Finaled: 4/27/2009 1.3 acre timber harvest, 2 stream crossings, 1200 ft road construction, 2150 ft road abandon FPA2611840 POPE RESOURCES F Application Received: 6/19/2012 Permit Issued/Case closed: 6/28/2012 Case Finaled: 6/29/2012 250 yards spoil areas and two culvert removals. BLD94-00457 US WEST NEWVECTOR GROUF F Application Received: 7/11/1994 Permit Issued/Case closed: 4/3/1995 Case Finaled: 6/29/1995 150 ft high cellular communications tower w/1-12'x 12'& 1 12'x 28' utility bldgs BLD97-00651 AIRTOUCH CELLULAR F Application Received: 10/3/1997 Permit Issued/Case closed: 10/9/1997 Case Finaled: 1/5/1999 EXTEND EXISITNG 150' CELLULAR TOWER TO 188' TIP HEIGH I. BLD99-00399 GRIFFIN F Application Received: 6/23/1999 Permit Issued/Case closed: 9/1/1999 Case Finaled: 11/16/1999 construct wireless communication equipment and antennas IZA94-00044 US WEST NEWVECTOR GROUF F Application Received: 7/1/1994 Permit Issued/Case closed: 9/6.11994 Case Finaled: 8/20/1996 to construct a cellular communications facility consisting of 150 ft high selt-supporting lattice tower and a 12 ft by 12 ft prefabricated equipment building. PRE99-00040 VOICE STREAM WIRELESS F J SMITH Application Received: 8/18/1999 Permit Issued/Case closed: 9/9/1999 Case Finaled: Voice Stream Wireless proposes to construct a 170 foot lattice tower to support a three-sector antenna array with (3) antennas per sector (9 antennas total). MLA01-00574 BLD01-00652 MLA01-00574 OLYMPIC RESOURCE MANAGE I F J SMITH Application Received: 11/20/2001 Permit Issued/Case closed: 11/28/2001 Case Finaled: 11/12/2002 ADD 4 ft. MICROWAVE DISH I0 EXISTING CELL TOWER @ 110 M LA02-00151 BLD02-00165 MLA02-00151 AMERICAN TOWER I F J SMITH Application Received: 3/26/2002 Permit Issued/Case closed: 4/30/2002 Case Finaled: 7/30/2002 COMMERCIAL EQUIPMEN f BUILDING \\tidemark\data\forms\R_Parcel_CRMLA.rpt 9/4/2014 Page 3 of4 MLA02-00157 • BLD02-00172 MLA02-00157 CINGULAR WIRELESS F J SMITH Application Received: 3/27/2002 Permit Issued/Case closed: 7/9/2002 Case Finaled: 4/1/2003 ATTACHMENT OF AN I ENNAS ON EXISTING TOWER MLA02-00250 BLD02-00258 MLA02-00250 AT&T WIRELESS SERVICES I F J SMITH Application Received: 5/2/2002 Permit Issued/Case closed: 8/19/2002 Case Finaled: 3/27/2003 REPLACEMENT OF EXISITNG ANTENNA FACILITIES ON EXIS I ING I OWER MLA08-00395 BLD08-00381 MLA08-00395 VERIZON WIRELESS I F Cara Leckenby Application Received: 8/25/2008 Permit Issued/Case closed: 11/18/2008 Case Finaled: 4/16/2009 INSTALL A 2' MICROWAVE DISH AND ELLIPTICAL WAVEGUIDE CABLE TO AN EXISTING WIRELESS COMMUNICATIONS STRUCTURE PRJ08-00107 MLA08-00395 VERIZON WIRELESS P Application Received: 9/3/2008 Permit Issued/Case closed: Case Finaled: MLA09-00208 BLD09-00186 MLA09-00208 POPE RESOURCES I C Michelle Farfan Application Received: 6/25/2009 Permit Issued/Case closed: 9/28/2009 Case Finaled: REPLACE 4 OMNI AN I ENNAS WITH 12 PANEL ANTENNAS - PENMI I CANCELLED DUE TO NON-PYMNT UNDER AMNESTY PROG M LA10-00171 BLD10-00143 MLA10-00171 POPE RESOURCES I C Zoe Ann Lamp Application Received: 5/5/2010 Permit Issued/Case closed: 6/24/2010 Case Finaled: MODIFY TELECOMMUNCAI IONS FACILITY- REMOVE & REPLACE 3 PANEL ANTENNAS, ADD 3 TMA's, 3 RUNS OF COAX CABLE, 6 DIPLEXORS &A RET SYSTEM &ATTACH UMTS RADIO CABINET TO EXISTING SLAB - PERMIT CANCELLED DUE TO NON-PYMNT UNDER AMNESTY PROG M LA11-00093 ' BLD11-00102 MLA11-00093 VERIZON WIRELESS I F Zoe Ann Lamp Application Received: 4/27/2011 Permit Issued/Case closed: 6/20/2011 Case Finaled: 2/13/2012 MODIFICATION OF EXIS I ING WIRELESS FACILITY- REMOVE & REPLACE 4 OMNI ANTENNAS WI I H 12 PANEL ANNTENNAS &ADD 1 MICROWAVE DISH M LA12-00026 BLD12-00043 MLA12-00026 AT&T I S David Wayne Johnson Application Received: 2/13/2012 Permit Issued/Case closed: 11/21/2012 Case Finaled: ADD 2 NEW 4' MICROWAVE DISHES ON EXISTING TOWER &4 NEW LINES OF COAX CABLE ZON99-00058 VOICE STREAM WIRELESS F J SMITH Application Received: 12/20/1999 Permit Issued/Case closed: 11/7/2000 Case Finaled: 4/29/2002 Construct a new 195 foot lattice tower to support a 3 sector panel antenna array with 3 antennas per sector(9 antennas total) . Equipment cabinet to be placed near tower base within a 40' x 40' lease area. In addition, Voice Stream may elect to mount up to three (3) microwave dish antennas onto the tower in the future. ZON95-00004 US WEST NEWVECTOR GROUF F J SMITH Application Received: 2/6/1995 Permit Issued/Case closed: 3/27/1995 Case Finaled: 12/13/1999 to construct a cellular communication facility consisting of one 12 X 12 building, one 12 X 20 building and a 150 foot steel self support antenna tower. \\tidemark\data\forms\R_Parcel_CRMLA.rpt 9/4/2014 Page 4of4 !UILDING PERMIT APPLICATN BLD14-00318 Review Type: Jefferson County Department of Community Development r coo.re(' 3.. 621 Sheridan Street Port Townsend, WA 98368 f3fut}t,Il PERMIT#: BLD14-00318 Received Date: 9/3/2014 J SITE ADDRESS: 2755 TARBOO LAKE RD QUILCENE, 98376 OWNER: POPE RESOURCES PHONE: C/O OLYMPIC RESOURCE MGMT 19950 7TH AVE NE#200 POULSBO WA 98370 SUBDIVISION: Block: Lot: TX 1+ PARCEL NUMBER: 801181001 Section: 18 Township: 28 N Range: 1V1 CONTRACTOR: TBD PHONE: 253-584-6606 REPRESENTATIVE: LYNX CONSULTING PHONE: 206-972-1368 17311 135TH AVE NE SUITE A-100 WOODINVILLE WA 98072 PROJECT DESCRIPTIOD SPRINT PROPOSED TO MODIFY ITS ANTENNA EQUIPMENT TELECOMMUNICATIONS TOWER. THE OVER ALL HEIGHT OF THE TOWER WILL NOT INCREASE. ADDIND ADDITION OF 3 PANEL ANTENNAS, 3 RRHS, 6 CYLINDERS AND 1 FILTER. THERE ARE NO CHANGES AT THE GROUND LEVEL OR ANY SITE DISTRUBANCE. TYPE OF WORK COM SQUARE FOOTAGE: COMMERCIAL: TYPE OF IMP ALT MAIN: INDUSTRIAL: VALUATION 10,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2012 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: NUMBER OF EMPLOYEES: WATER SYSTEM: BATHROOMS: Exist: Prop: Total: Routing Date: Type Amount aid By: Date: Receipt: • Approved/Date Permit $168.00 SRE 09/03/14 151503 Plan Check $109.20 SRE 09/03/14 151503 State Building Code $4.50 SRE 09/03/14 151503 Total: $281.70 1ltidemark\data\forms\F_BLD_App_Bld.rpt 9/3/2014 LYNX CONSULat4If14 Jefferson County 3192 SPR2.5.2WESTWASHINGTON01/Project ManagemE 528.70 B of A-0117 Sprint 82962/SE33XC013-LU & BP Fee 528.70 JEFFERSON COUNTY M NO. 15150`3 ( V DATE ckJ3/ I q RECEIVED FROM vt a0.�Inc , 1YIC DESCRIPTION u /BARS# AMOUNT CURRENCY z.o /toN (Irv, (9 • U U ��1 ! Q P- COIN Q,(i�I� �, / l��q V0 P ?'.. �RECK3 r-�fwlan V Ili 1 . z"° )G2 Scan I c?' c I -19, -0D\ Si-c tc LI s� o ,, m F fin,: J 0/��d 0 RECEIVED BY Ll l • TOTAL 52-- . fu 1 Q50N ' �4w °off JE RSON COUNTY 1 I V { DEPARTMENT OF COMMUNITY l E v' "3 " 621 Sheridan Street Port Townsend,WA 98368 Web:www.co.idfferSoniwa.us/communitvdevelo�tme 9sy1 no�o Tel:360.379.4450 I Fax:360.379.4451 I Email:dcd(chco.iefferson,Wa us F — �� Building Permits &Inspections I Development Consistency Review I Long Range Planning I Watersheds : . : ;: ' V-• er rr -ro 11 1 Master Permit Application MLA: ,,,-PT.or COMMUNITY DEVfLOPMFNT Project Description(include separate sheets as necessary): Sprint proposes to modify its antenna equipment on the existing telecommunications tower.The over-all height of the tower will not increase. Tax Parcel Number: 801181001 Property Size: j if j (acre square feet) Site Address and/or Directions to Property:2755 Tarboo Lake Rd,Quilcene,WA 98376 2-6/U2- TOWFR nPFR.ATnR 33)(C o)3 tazaatumurts)of Record: 4rfl& l'L iLfl --rowe,r Tv a-et re CIY"It t-$ t) Telephone:,2)-9 2-(1" © Fax:7 email: Mailing Address: f 6 r rLQ1/ C!2'f7 ` 1/�d-y , lVd U n1 r M/3 I$0 ) Applicant/Agent(if different from owner): I ynx Consulting, Alec?. 'Z_, c/n Sprint Telephone 0Ln ' 1c- 1 Fax: 4.25 3.5 Li 34.7.7 emaii.,ZGiVcilC, ") ;'‘2 Mailing Address: 17311 135th Ave NE,Suite A-100,Woodinville,WA 98072 C Ci`-.5 U 1-I'i What kind of Permit? (Check each box that applies ❑ Lot or Road Segregation BBuilding ❑ Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor, Major or Reasonable Economic Use) ❑Single Family El Garage Attached/Detached ❑Conditional Use[C(a), C(d), or C]'" ❑ Manufactured Home ❑ Modular ❑ Discretionary"D"or Unnamed Use Classification PI Commercial* ❑ Special Use(Essential Public Facilities)" ❑ Change of Use El Boundary Line Adjustment ❑ Address El Road Approach ❑ Short Plat** ❑Home Business ❑Cottage Industry ❑ Binding Site Plan** ❑Propane El Long Plat** ❑Sign ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑Allowed"Yes"Use Consistency Analysis ❑ Plat Vacation/Alteration*" ❑Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions'"' ❑Site Plan Approval Advance Determination(SPAAD)* ❑Shoreline Management Substantial Development** ❑Temporary Use ❑Shoreline Management Variance B Wireless Telecommunication* ❑Comprehensive Plan/UDC/Land Use District Map Amendment ❑Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference ❑ Tree Vegetation Request **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: Lynx Consul j z DESIGNATION OF AGENT I hereby designate y Y to act as my agent in matters relating to this application for permit(s). TOWER By:Consul _ / 3y ouiu-i Date: A #7 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 its 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 r-.uied later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap'i io that - • she wants •ri r otice. Signature: " t- , �� Date: Zf The action or actions Applic nr'll 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 ou re in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfe ble eAsponsibili or adhering to and complying with the ESA. The Applicant has read this disci Timer and signs a d dates it below. Signature: V 4. Date: Q y^ 07/24/2013 • II ,,,z,Y. rocy JEFFERSON COON'('Y DEPARTMENT OF COMMUNITY DEVEL T `,. a 621 Sheridan Street j Part Townsend,WA 9836B Web: , aco.jeff sc s :r'muiiTWde , merit ry'1 c' Tel:360.373.445C I Fax:360.379.4451 j Email.dcdta7-co.leftersen.wa.us I I Building Permits&Inspections(Development Consistency Review Long Range Planning Watershed Stewardship Resource Cerir&r Master Permit Application MLA ---J It4 Project Description(include separate sheets as necessa ry): Sprint proposes to modify its antenna equipment on the existing telecommunications tower.The over-all height of the tower will not Increase. Tax Parcel Number. 801181001 Property Size: Lib (.(acre square feet) Site Address and/or Directions to Property:2755 Tarboo Lake Rd,Ouilcene,WA 98376 4 2�11Z TOWER oPFRATOR — • cC _ 33X<G�1 3 mss)of Record: ) 'fl'Can 'TdWer — f'ra re '( l'Y� (-VJ Telephone: 7 7)-el L(I 5-40 Fax: email: Mailing Address: t b d r��l� �fi a.G /ar✓ , ��D�,u en r /} Z a l Applicant/Agent(if different from owner): I ynx Consulting,faker, Z ., C/o Sprint Telephone .00 &T7 c7-- 1 .7 Fax: 2 S 391 3'}-7 7 email./qt'tvC4 fCS ;") !y Mailing Address: 17311 135th Ave NE,Suite A•100,Woodinville.WA 98072 (&—\s�,1 11hL � „ J �J'�_ What kind of Permit?(Check each box that applies ❑Lot or Road Segregation Building ❑Critical Areas Stewardship Plan ❑ Demolition Permit ❑Variance(Minor,Major or Reasonable Economic Use) ❑Single Family ❑Garage Attached/Detached ❑Conditional Use(C(a), C(d),or Cj" ❑ Manufactured Home ❑ Modular ❑Discretionary"Cr or Unnamed Use Classification 9 Commercial* ❑Special Use(Essential Public Facilities)" ❑ Change of Use ❑Boundary Line Adjustment ❑ Address ❑ Road Approach ❑Short Plat" ❑Home Business ❑Cottage Industry ❑Binding Site Plan" ❑Propane ❑Long Plat" ❑Sign ❑Planned Rural Residential Development(PRRD)/Amendments" ❑Allowed°Yes"Use Consistency Analysis ❑Plat Vacation/Alteration" ❑Stormwater Management ❑Shoreline Master Program Exemption/Permit Revisions" ❑Site Plan Approval Advance Determination(SPAAD)" ❑ Shoreline Management Substantial Development" ❑Temporary Use ❑ Shoreline Management Variance 9 Wireless Telecommunication" ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Forest Practices Act/Release of Six-Year Moratorium ❑Jefferson County Shoreline Master Program Amendment *May require a Pre—Application Conference ❑Tree Vegetation Request "Requires a Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, If known: Lynx Consul DESIGNATION OF AGENT I hereby designate y to act as my agent in matters relating to this application for permits)- TOWER OPERATOR By (-1('('/A /e ( (Date: e'( (OE / 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 its 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,indemnity and hold harmless Jefferson County against all liabilities,Judgments,court costs,reasonable attorneys 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 r ui ed later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap that - • she wa is .riar>>notice. ((-�� I , Signature: 1---- ...d t-6 . Dale: 7J ` 1 1 ` j L The action or actions Applic: 11 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 ou re in compliance with the Jefferson County development code The Applicant acknowledges that he,she or it holds individual and non-Iransfe, bie ponsibili or adhering to and complying with the ESA. The Applicant has read this disc) imer and signs a d dates it below. Signature (- __ ay / a t�' y— Date: 0 ! /LI 1 17/24/2.011 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 asiiming the responsibility of the General Contractor for the proposed project. Sgnatun _ Date: ____ GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: I -7\ L `V",PHONE' i� a ; i FAX r� ) ,I' I ( ) MAILING ADDRESS: EMAIL: - CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE.,( _ ) _-- FAX:( ) MAILING ADDRESS: EMAIL P New Type: o Wood p Existing:ms: i ' Shoreline: ---Type of Sewage Disposal: Project T e: Frame Type: � Bathrooms: ' A• 0 Sewer O Addition o Steel Proposed: Bank 0 Community System 'Alteration/Remodel 0 Concrete Total: Heigh4 0 Individual System i1 i" '* O Repair u Masonry '' SEP Permit# O Demolition Bedrooms: Other. Water Supply: AOM Existing: Setback: 0 Private well , f) Iwo Party Typepf Heat: Proposed: O Public )• /il-- 1 I Pr Total: Name of System: If this Is a Commercial Proiect you must answer the following: �/ Number of Parking Spaces: Current: Proposed: --C/ Number of AQA Parking Spaces: Number of occupants includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: \J- X IBC Type of construction: Ol i Will you have Food Service? Yes No If this is a P o•ane Tank an•IorA••Hance Installation •ermit ma all items below that a••I : I Underground Tank I Above ground Tank Size of Propane Tank: I Heat Stove I Cook Stove I Woodstove I Fireplace Insert I Hot Water Tank I Pellet Stove I 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 properly 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•Of ie c� Use:4Only Amount Revision Main Floor Heated ;::,`%._ EH Bld App Review: 28°Floor Heated Consistency Review: Other Heated Base fee: } Mezzanine Additional Section: Iq Heated Basement Plan Check fee: \Vc Unheated Basement State Surcharge fee: t, Other Unheated Pot Water Review fee: Garage/Carport 'r SUBTOTAL ri sz- . i" a Decks (( 911/Rd Approach fee: Other •-4,'V)hiYMlt m G/.'1 TOTAL $ -- '---- n Receipt Number: i 5 i Cash/Check Number: i�,� •-� ESTIMATED COST(REQUIRED) Date: r l L/- .Fair market value of all labor and vmaterials foundation to finish 1C / t 0 ` y1 -- Initials: • /- G.\PerntitC enter\lAt#FORMS###WItD FORMS\Master Permit Application 5-29-08.doc 0 0 i r ON eQ�� JEFFERSON COUNTY , DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street• Port Townsend •Washington 98368 4,s, O 360/379-4450 • 360/379-4451 Fax http:llwww.co.jefferson.wa.us/commdevelopment/ '_ - Stormwater Calculation Worksheet { '7' s �" MLA# PROJECT/APPLICANT NAME: 4)&04, i,'(,(�d , 1.L✓ ,,, ,,..th.y DETERMINING STORMWATER MANAGEMENT REQUIREMENTS: This stormwater calculation worksheet should be completed first to classify the proposal as°small""medium,"or'large.' The size determines whether a Stormwater Site Plan is required in conjunction with a stand-alone stormwater management permit application, building permit application, or other land use approval application that involves stormwater review. The basic information will also be helpful for completing a Stormwater Site Plan,if required. / PARCEL SIZE(LE.,SITE), Size of parcetta� acre An acre contains 43,560 square feet. Multiply the acreage by this figure. Size of parcel in square feet . CG-7. 5/daft Land-disturbing activity is any activity that results In movement of earth, or a change in the existing soil cover(both vegetative and non-vegetative) and/or the existing soil topography. Land disturbing activities include, but are not limited to clearing,grading, filling, excavation,and compaction associated with stabilization of structures and road construction. Native vegetation is vegetation comprised on plant species,other than noxious weeds,that are indigenous to the coastal region of the Pacific Northwest and which reasonably could have been expected to naturally occur on the site. Examples include species such as Douglas fir,western hemlock,western red cedar,alder,big-leaf maple,and vine maple;shrubs such as willow,elderberry,salmonberry, and salal;herbaceous plants such as sword fern,foam flower,and fireweed. LAND DISTURBING ACTIVITY, CONVERSION OF NATIVE VEGETATION, AND VOLUME OF CUT/FILL Calculate the total area to be cleared,graded,filled, Answer the following two questions related to excavated,and/or compacted for proposed development conversion of native vegetation: project. Include in this calculation the area to be cleared for: Does the project convert%acres or more of Construction site for structures sq/ft native vegetation to lawn or landscaped areas? Drainfeid,septic tank,etc. sq/ft Circle: Yes 4/ap Well,utilities,etc. sq/ft Does the project convert 2%acres or more of y native vegetation to pasture?� 4-91-- Yr/ Driveway, parking, roads,etc. sq/ft Circle: Yes Lawn,landscaping,etc. sq/ft Other compacted surface,etc. ' t) sq/ft Indicate Total Volumes of�Prro,�posse�d: Total Land Disturbance �rv' '" sq/ft Cut N'v Fill lV t+' 2 (cu/yd) [oven stormwatnr cart wokshaei—REV 2/2012000 1 II ,` ._ Impervious surface is a hard surface that either prevents or retards the entry of water into the soil mantle as under natural conditions prior to development. A hard surface area which causes water to run off the surface in greater quantities or at an increased rate of flow from the flow present under natural conditions prior to development. Common impervious surfaces include, but are not limited to roof tops, walkways, patios, driveways, parking lots or storage areas, concrete or asphalt paving, gravel roads, packed earthen Materials, and oiled, macadam or other surfaces which similarly impede the natural infiltration of stormwater. STORMWATER CALULATIONS-IMPERVIOUS SURFACE NEW EXISTING n"leht: A4_, cy- Structures(all roof area) sq/ft Structures(all roof area) `tre" sq/ft Sidewalks a sq/ft Sidewalks sq/ft Patios sq/ft Patios sq/ft Solid Decks -e sq/ft Solid Decks sq/ft (without infiltration below) (without infiltration below) Driveway,parking,roads,etc sq/ft Driveway, parking,roads,etc sq/ft Other YYtON'j 1)._. sq/ft Other sq/ft Total New .411- sq/ft Total Existing sglft TOTAL NEW+TOTAL EXISTING' -"CJ sq/ft This amount will be used to check total lot coverage. The following questions will help determine whether the proposed project is considered development or redevelopment. DEVELOPMENT v.REDEVELOPMENT Divide the total existing impervious surface above by the size of the parcel and convert to a percentage: % Does the site have 35%or more of existing impervious surface? Circle: Yes 'N35 FURTHER INSTRUCTIONS: If the answer is yes, the proposal is considered redevelopment and the attached Figure 2 should be used to determine the applicable Minimum Requirements. If the answer is no, the proposal is considered new development and the attached Figure 1 should be used. At this juncture,the applicant should refer to the applicable Flow Chart to determine the Minimum Requirements for stormwater management. DCD staff will help verify the classification of the project and the application requirements. For proponents of "small" projects who must comply only with Minimum Requirement #2—Construction Stormwater Pollution Prevention—an additional submittal is not required. The proponent is responsible for employing the 12 Elements to control erosion and prevent sediment and other pollutants from leaving the Site during the construction phase of the project. Pick up the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet, Proponents of"medium° projects—those that must meet only Minimum Requirements #1 through #5—and for 'large" projects—those that must meet all 10 Minimum Requirements—are required to submit a Stormwater Site Plan. DCD has prepared a submittal template of a Stormwater Site Plan, principally for rural residential projects. Complete the template in the Stormwater Site Plan Instructions and Submittal Template or prepare a Stormwater Site Plan using the step-by-step guidance in the Stormwaler Management Manual. APPLICANT SIGNATURE By signing the Stormwater Calculation Worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all • owner of the affected property. (LANDOWNER OR AUT )��Rlyj{,5OO REPRESENTATIVE SIGNATURE) (DATE) / / L R ""-P 9 � :A''), f 1r ,C w+ : ''...4151b*,- --." ri=f; 1 .u' t <i.44-is bf.: '.:*,,i , 1,,,,cSr 4,1.4„.-44 g ,, tr, , etC'� i yy` 0t z ' ;, mv €.._ 'Si l-L ,y^ .Ariloti: :_ t �'u .4 wO. Y L 1, pTFV �P A .#' ,..4§14-. 7_:,6 affz.: g " AL.-: P'''7: .; '. a,. srormwaizr cem warkaheei-REV.220(296 2 • Lv' NIX August 14, 2014 Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 RE: Sprint SE33XC013 Tarboo Lake/ATC82962 at 2755 Tarboo Lake Road, Quilcene, Parcel No. 801181001, Antenna Modification, Request for Zoning Approval and Building Permit Dear DCD: On behalf of Sprint, Lynx Consulting is submitting to Jefferson County a request for zoning and building permit approval, for modifications to an existing wireless facility located at 2755 Tarboo Lake Road, Quilcene. Specifically, Sprint proposes to modify the existing wireless facility with the addition of three panel antennas, three RRHs, six cylinders and one filter. The existing facility is a 177'0"tall self- support/lattice tower. Sprint presently has an existing antenna mount with three panel antennas; the rad center of antennas is 167'0"AGL. The new antennas will be mounted on the existing mount at the same height as the existing. There are no changes at the ground level or any site disturbance. Enclosed please find the following: • One Master Permit Application • Three sets of construction drawings (11 x 17") prepared by Lynx Consulting • Three Structural Analysis Report dated 8/14/2014 prepared by ATC supporting the proposed antenna modification • Check in the amount of$528.70 (Land Use fee of$228 and the balance is based upon the project's valuation of$10,000 per Mary of your office -building permit fee is $300.70) If you have any questions or need additional information in order to deem this application complete please call me at 20 6 972 1368; my email is Azavales ,,lynxconsulting.org. Thank you for your consideration. Sire re y, 'Aileen avales Lynx Consul • g Enclosures t Pal2, e 17311 135th Avenue NE, Suite A-100, Woodinville,WA 98072 MOL -' 2&73 RfC�',rt$ OF OFFICM,MC RECQRDS REQUEST OF • i = \ . AUG 29 F4fi a;;; 58 R ''�� ota ,�`$�a �iner - I • Piled [or record at uqueat of •' • , 1 • ) recorded When rerded retturn to: i ^ S: •,_� U t ttar Groopo Inc.. APT,.:: Real [state and Construction Dept. 3190 161st Ave. 8t P.O. tot 91211 Rellsrue, Va. 91009-1111 .:'a•..=.s: ,c- _ .'lime" MEMORANDUM OF OPTION AND LEASE AGREEMENT This Memorandum dated this 714'1-` day of tVIll fJ_f-1 , 1994, by and between Pope Resources, a Delaware Limited Partnership, (hereinafter "Lessor") and San Juan Cellular Limited Partnership, P.O. Box 91211; Bellevue, Washington 98009-9211 (hereinafter "Lessee" ) , is a record of that Option and Lease Agreement (hereinafter "Agreement") between Lessor and Lessee dated Ake. ! -t 7, (49q , which Agreement includes in part the following terms: 1 . Leased Premises. The Agreement pertains to real property which is described in Exhibit "A" (hereinafter "Property") , which is attached hereto and incorporated herein by this reference. 2. Term of Agreement and Options to Extend. The initial term of the Agreement is for a five-year (5) period commencing on the date the Option is exercised by Lessee. Lessee has options to extend the Agreement term for four consecutive five-year (5) periods. Lessee may, under certain conditions, elect to further extend the term thereof. 3. Successors and Assigns. The terms, covenants and provisions of the Agreement extend to and are binding upon the respective executors, administrators, heirs, successors and assigns of Lessor and Lessee. 4. Ratification of Lease. The parties by this Memorandum intend to record a reference to the Agreement and do hereby ratify and confirm all of the terms and conditions of the Agreement and do hereby declare that the real property described in Exhibit "A" attached hereto is in all respects subject to all of the applicable provisions contained in the Agreement. NO Crtveo TATS AES T� Pe" .T . " "" ASURER By 111- 411 LESSOR: Pope Resources, a Delaware Limited Partnership, by Pope MGP, Inc_ , its Managing General Partner By: Its: Date: 31-7 �Cl LESSEE: San Juan Cellular Limited Partnership, by U S WEST NewVector Group, Inc. , as it neral Partner By: Its: Director Field Operations Date: q--zn -9Si NoLao, 9-I-93 2 STATE OF WASHINGTud ) )ss. COUNTY OF KING 2,--LL ) On this ]ay �of ��'_ ( , 1994, before me personally appeared �t.IX - , to me known to be the prof U S W ST NewVector Group, Inc. , the general partner o San Juan Cellular Limited Partnership, the partnership that executed the within and foregoing instrument, and acknowledged said instrument to be the free and voluntary act and deed of said partnership, for the us.M and purposes therein mentioned, and on oath stated that �. was authorized to execute said instrument and that the seal affixed, if any, is the seal of said partnership. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal t1l _.$av and year first abAye written. tttttttttttttt 0 N:5-7----) ,mss% _�.QISA fjLCC #iii ,, !t`.:•'4iONk. O i Notar lic in and for the ,F� Q�9' o NOTARY Fm: St e of Wa h'ngtorL. - : -,►- residing at l.0 • \ �u� , � ��e � My appointment a ires : A v., `‘ I. -7 •,A/� 29 ,si:Ck0. Type or print tary's Name: �,F`O. ' 0�t.� tttttttttttttttt CORPORATE ACKNOWLEDGMENT STATE OF Washington ) )SS. COUNTY OF Kitsap ) On this 7' - day of k--,1//7)-z)/-0/i . , 1994, before me personally appeared 67 /-/ --^/�/•;«.T , to me known to be the l' - of Pope MGP•, Inc. , the corporation that executed the within and foregoing instrument as General Partner of Pope Resources, a Delaware Limited Partnership, and acknowledged said instrument to be the free and voluntary act and deed of said corporation, for the uses and purposes therein mentioned, and on oath stated that ,e was authorized to execute said instrument and that the seal affixed, if any, is the corporate seal of said corporation. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my ,.nom 6-itI4.cial seal the day and year first above written. „.:f --ss.".„.-,V5,517.7!•- • -• M /'!�/ 7 -Q-- 7-/7r' C "=-i' 7Public in and for the •107 te; of/ washg on 4 r idp.nt at _ , (-.-n,• , ?--rz,. __ fi kr•, yP�i ap�,rntment expires: - /- ?"-- yj.;4,;-,1Tr e 'bx:' Print Notary's Name: (11% OF swop\C�� A_i,, -, /�' SZ.e r' _ • Wal Gardiner Exhibit "A" Legal Description A portion of the NW 1/4 of Section 18, Township 28 North, Range 1 West, consisting of a parcel containing 3 ,000 square feet. A full legal description of the Property will be inserted upon receipt of the survey. +�-A-,�-- n naf 11•a.01w.■a,Io.*UM UMW R aC mn "41M """` Access via existing alllml„IV.e a.I.11I. togging road to SR 104 SEC 8 114.1.411+.4.O M 9C1.Y 1 11 ( (1-214.41 at TWP 28N 1 � RGE 1W ,1 531f w w VdE (04!0 a- aC11(AM UW0 `Qt 1 1 \ c 0f UK( f 11060.IESS us+) 1 1 7001.(6.1 1 1 I 1 1 LEASED AREA + \\A //� ,' 50' x 60' Go•I t ,..(0 11` , 1 1 1 1 1 `, v 1 11 (.IgeW 1 i 30ue1001 E,IyC g0a0 1 1 AU.0(S(COCMIASS 'G "6 1 k 6/.1 5/CASE 'i m 1 135.13 I. - ki it?, '� ia1C DJI a.WI LAKE] 01 ' % 1 S I\ 1 COS° '1 `I SCALE: 5 1 1%.400 1 1 1 1 ti 1 1 i i 1 1 1 1 1 1 1 1 1 1 1 1_G1 1 1 GOB 1 1 1. 4 1 1 4 DAM. i 1 Intl". i 1 PC0151d15 q ie I 1 1rnn1 n 4(19 IAM] a• ' 119-Ln_Iq "j'1 —JEFFERSON COUNTY ASSESSOR— 6011900 • COA RECORDING REQUESTED BY AND WHEN RECORDED RETURN TO: SULLIVAN WORCESTER LLP One Post Office Square Boston,MA 02109 TT �T /� Attn: Dianne M. Cosman,Paralegal ORIGINAL V AL (Space above this line for Recorder's Use) -_^h�MORANDUM OF SUE •-LEASE This MEMORANDUM OF SUBLEASE, made and eennterdd into as of this 1st day of May, 2001 by and between SEATTLE SMSA LIMITED PARTNERSHIP, a Delaware limited partnership ("Sublessor")* and American Tower Delaware Corporation, a Delaware corporation ("Sublessee")**. I. Pursuant to Site Designation Supplement number 522,effective May 1,2001, which is governed by the terms and conditions of that certain Sublease entered into between Sublessor,Sublessee and other parties identified therein on January 19,2000 which is incorporated herein by this reference,Sublessor subleased to Sublessee, and Sublessee subleased from Sublessor,the Subleased Property(defined below). The Commencement Date for the Site Designation Supplement is May 1,2001. Notices with respect to the Site Designation Supplement shall be,in addition to the notice address in the Sublease,directed to: Verizon Wireless(VAW) LLC 180 Washington Valley Road Bedminster,New Jersey 07921 2. The Subleased Property subleased to Sublessee under the Site Designation Supplement is a portion of the real property commonly known as WA I GARDINER-522 and more specifically described in Schedule I attached hereto. 3. In the event of any conflict between this Memorandum of Sublease and the Sublease(and Site Designation Supplement),the terms of the Sublease(and Site Designation Supplement)shall control. *Address of Sublessor: "Address of Sublessee: c/o Verizon Wireless (VAW) LLC c/o American Towers, Inc. 180 Washington Valley Road 116 Huntington Ave., 11th Floor Bedminster,New Jersey 07921 Boston, MA 02116 Project Vertical Number-522 IN WITNESS WHEREOF, Sublessor and Sublessee have duly executed this Memorandum of Sublease as of the day and year above written. SUBLESSOR: SUBLESSEE: SEATTLE SMSA LIMITED PARTNERSHIP, AMERICAN TOWER DELAWARE a Delaware limited partnership, d/b/a Verizon CORPORATION, a Delaware corporation Wireless By: VERIZON WIRELESS(VAN) a Delaware limited liability company, By: ' �i�✓ its general partner Joni than R. Black Vici President By: CELLCO PARTNERSHIP, a Delaware Partnership, its sole member By: tka/�t /let- Bernadette Faiella Acting Executive Vice President and CTO Date: q//a—/ 0 / Date: i !i") 1` l Tax ID No.: Tax ID No. 3481371 PV 522 • • STATE OF NEW JERSEY Somerset County • ri On this a , fr -W2001, before me, /1//477ii.i,r 4z /C c 2d a f - o l`a i 'Publio in and f o r said Co tialty and State,personally ap2eared Bernadette Faiella, Acting Executive Vice President and CTO of CELLCO PARTNERSHIP„ who acknowledged that he/she did sign the foregoing instrument and that the same was her free act and deed as such Acting Executive Vice President and CEO and the free act and deed of CELLCO PARTNERSHIP. WITNESS my hand and seal this /-1.2-/-7 day of , 2001. (Print Name) Notary Public My Commission Expires: ANN£TT8 VAN?ASset, !Votary Public of New Jersy ay Coarrisslort Expires Marsh 03,2004 PV 522 • CORPORATE ACKNOWLEDGEMENT COMMONWEALTH OF MASSACHUSETTS) ) ss COUNTY OF SUFFOLK "'- " ) On this day of Ate '� , 2001, before me,the undersigned, a Notary Public in and for the Commonwealth of Massachusetts, duly commissioned and sworn, personally appeared Jonathan R. Black, to me known to be the Vice President of American Tower Delaware Corporation, a Delaware corporation, the corporation that executed the foregoing instrument and acknowledged the said instrument to be the free and voluntary act and deed of said corporation for the uses and purposes therein mentioned, and on oath stated that he is authorized to execute the said instrument. WITNESS my hand and official seal hereto affixed the day and year first above written. (Print Name) (- fir/ee,-L A. G'6( Notary Public in and for the Commonwealth of Massachusetts My commission expires: I'1/' f ='C2 PV 522 0 - - .- SITE DESIGNATION SUPPLEMENT NUMBER 522 This Site Designation Supplement is governed by the terms and conditions of that certain Sublease entered into between AirTouch Communications,Inc., American Tower Delaware Corporation and the other parties named therein, on January 19, 2000, which is incorporated herein by this reference. The Commencement Date for this Site Designation Supplement is May 1, 2001. This Site Designs .Sqpple'ment relates to "Project Vertical Site Number"522. Schedule 1 ("Legal Description of Sublessor's Property") and Schedule 2 ("Description of Subleased Property")attached hereto are hereby incorporated into this Site Designation Supplement by this reference. Concurrent herewith, a"Memorandum of Sublease" is being prepared and executed by "Sublessor"and "Sublessee"(each as defined in the Memorandum of Sublease), which Memorandum of Sublease corresponds with this Site Designation Supplement. This Site Designation Supplement shall be deemed to be duly executed and approved by Sublessor and Sublessee upon execution by such parties of the corresponding Memorandum of Sublease. 2 �aCu • 1J c?S OUNN1 JL f 'n�T ire; n+CG iU � Yria0 ,E,, PV No. 522 • Schedule 1 Page of LEGAL DESCRIPTION OF SUBLESSOR'S PROPERTY Street address:1696 STATE ROUTE 104 City: — v. - State: Washington �" " ' 3 " Zip: All that real property located in the State of Washington,County of JEFFERSON,described as follows: The Sublessor's property of which the Subleased Property is a part is legally described as follows: ON THE FOLLOWING PAGE: SITE ID: See Section 3 of Memorandum of Sublease GROUND LESSOR'S PROPERTY: See "Properly Legal Description' DESCRIPTION OF SU BLESSOR'S PROPERTY: See "Premises Description" if available �� c� � T` U, Project Vertical Number: 522 . - SCHEDULE 1' 1 Page ? of `\ 1 Wal Gardiner Exhibit "A" Legal Description A portion of the NW 1/4 of Section 18, Township 28 North, Range 1 West, consisting of a parcel containing 3,000 square feet. A full legal description of the Property will be inserted upon receipt of the survey; - { Access via existing logging road to SR 104 SEC 18. " r _ "-�•-•" • • TWP 28N "" 1 1 / " " RGE1W • 1 1 1(,1"...µq1 ' 1 (1MY• `Qt 1 1 - Y O IMt Y Z 1[D W 11 GO' A ■ t 1 1 rA1300 1 1 \LAKE , 1 1 1-1 • LEASED AREA • \ /'3'' 1 + 50' x 60' W1 1 i God t� , i1 1 i 1 ■ 1 1 1 1 1 I • 1 • E • i G 1 1V 1Ytyh LEW • II Go.r, �p1 112 11 k y 1•••400'■ 1 1 1 i 1 ' 1 1 1 • 1 1 1 1 1 1 • 1 1 1 1 ,Oi I 1 c .°' i 1 1 1 41 ow 1 11 1 1 MOWS ". 1 i "`' w. VOL 1011.41.-ml i 512 -r., 96 J COUNTY ASSESSOR- - � O I M .�•Pv# 52_2- S i SCHEDULE 1 Page 3 of BAIMA & HOLMBERG INC. WA1 GARDINER EXHIBIT "13'1 Legal Description n-w, SITE EASEMENT A 3,000 square foot site located in the Northwest Quarter of the Northwest Quarter of Section 18, Township 28 North, Range 1 West W.M. in Jefferson County, Washington. ACCESS EASEMENT A 20 foot wide strip of land, whose centerline follows the centerline of unnamed existing logging roads, as they exist in July, 1994, or as they may exist in the future, described as follows: Beginning at State Route 104 in Section 6, Township 28 North, Range 1 West H.M.; thence southerly thru the West half of Sections 6, 7, and 18 in said Township 28 North, Range 1 West W.M. to the Site Easement located in the Northwest Quarter of the Northwest Quarter of said Section 18. Length of Access Easement is approximately 1.2 road miles. es' gUP$11 �J • fco ! tx-T . 1 S ',11-- l; "•iLLAIm ...y XI- ✓1r1- vat 517 m„175 70588LGL-7.22.94 100 FRONT STREET SOUTH • ISSAQUAH • WASHINGTON • 98027-3817 • (206)392-0250 • FAX(206)391-3055 PV# 5 22 • • SCHEDULE I Page t of . • Exhibit "A-1" WA1 GARDINER SITE, ACCESS AND UTILITY EASEMENT A PORTION OF THE NORTHWEST QUARTER OF SECTION 18, TOWNSHIP 28 NORT,FU._RANG_E 1 WEST, H.M. , IN JEFFERSON COUNTY, WASHINGTOtr D)SCRIBED .AS FOLLOWS: COMMENCING AT THE?NORTHWEST CORNER OF-MID SECTION 18; • THENCE S 39°06'03" E, A DISTANCE OF 2146.49 FEET TO THE TRUE POINT OF BEGINNING; THENCE S 00°00'00" W, A DISTANCE OF 60.00 FEET: THENCE N 90°00'00" E, A DISTANCE OF 50.00 FEET TO REFERENCE POINT "A"; THENCE N 00°00'00' E. A DISTANCE OF 60.00 FEET; THENCE N 90°00'00" W, A DISTANCE OF 50.00 FEET TO THE TRUE POINT OF BEGINNING; TOGETHER WITH A 40 FOOT WIDE ACCESS AND UTILITY EASEMENT BEING 20 FEET ON EITHER SIDE OF THE FOLLOWING DESCRIBED CENTERLINE: BEGINNING AT SAID REFERENCE POINT "A"; THENCE S 00°46'25" E, A DISTANCE OF 133.24 FEET; THENCE S 33°35'48" E, A DISTANCE OF 84.81 FEET; THENCE S 10°53'25" E, A DISTANCE OF 137.23 FEET TO THE CENTERLINE OF AN UNNAMED EXISTING LOGGING ROAD; THENCE S 79°36'55" E. ALONG SAID UNNAMED ROAD, A DISTANCE OF 539.97 FEET; THENCE S 79°21'10" E, ALONG SAID UNNAMED ROAD, A DISTANCE OF 613.75 FEET; THENCE S 79°57'05" E, ALONG SAID UNNAMED ROAD, A DISTANCE OF 1249.83 FEET, MORE OR LESS, TO THE INTERSECTION WITH THE TARBOO LAKE COUNTY ROAD AND THE TERMINUS OF THIS ACCESS AND UTILITY EASEMENT. 70588REV/12.16.99 v%o sOPE/14 tI u1�+lw to GI 'r{ 339 rail ' F z Id.'444 LAtto S « 30 9C ,11 100 FRONT STREET SOUTH • ISSAQUAH • WASHINGTON • 86027-3317 • (206)392-0250 • FAX(206)391-3055 Pv# 52z r • Schedule 2 DESCRIPTION OF SUBLEASED PROPERTY The location of the Subleased Property within the Sublessor's property together with access, ingress,egress, easements and utilities are more particularly described or depicted as follows: A. Sublessor's Property described or depicted in Schedule 1 B.A 180 foot PIROD SSUP Tower and ground ring(if separate) C.All other physical improvements, less and except in each ins�ix - -- (1) the Reserved Space thereof described in Schedule 3; (2)any Sublessor's Improvements and Communications Equipment onrsuch Site,and (3)Improvements of Existing Space Subtenants described as follows: Ant Ctr Name of Tenant line(ft) Svc°Provided Ant Tyne No Ant Land Area Reserved Space Simmons Cellular of WA 140 CELLULAR DISH I Simmons Cellular of WA 145 Cellular WHIP I Simmons Cellular of WA 155 Cellular WHIP 2 Sprint Spectrum L.P. 168 PCS Panel 9 1-0) II 5. : _. I, I L, JEFFERSON COnlY DEPT.OF C0''?8'1NFIY DEVELOPl'EN' Project Vertical Number: 522 Schedule 3 RESERVED SPACE SUPPLEMENT -TX - [This is a replacement page; the actual Schedule 3 is on file'with American Tower Delaware Corporation.] • 1-1 N _ Nyi Li) i I ,f! Lit !•-•"'L JEFFERs,.. CU PV No. 522 Map Output • • Page 1 of 1 ArcIMS HTML Viewer Ma• y. r Cot � -7' .--'-''.-------'. � . i.. i J. el r I Oil I- `` i,..e',0. . wS y —, ' L .* c. Legend . Selected Feat ures yY r_ - i Township Lines ,'N'.-' r,. ---, '- - Major Roads ! , I +` °'- �, : /..../ Parcels-H �• ti�l LJ 2013 Aerial Photos i I w ',• I h ,—.' , :b. *, '.;- I -- ,.-42-111- t _ <, **(*;-4, I MaPs paraded by J•tkrun Corn)Cr rr4 ..ces Gq '" -___.---- ""."_•--0. `' FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. Thu Sep 04 08:56:56 2014 http://gisserver/servlet/com.esri.esrimap.Esrimap?ServiceName=ovmap&ClientVersion=4.0&Form=True&E... 9/4/2014 1 Map Output • 411 Page 1 of 2 ArcIMS HTML Viewer Map ' .il 1 a NM i L , ; 0 j 1 II 17 Ai.,`- re*or. _ ® 1 r- i 1-, ,_, , _____ , ,, .._.. i1 \ 9 ,,. i , „,, ,„, , i., _ F \1ax.:rcr.Jed.r._c'c-ui Curd Ccr.-a s-cx..GF] ;f- "',_•�.... http://gis server/servledcom.esri.esrimap.Esrimap?ServiceName=ovmap&C lientV ersion=4.0&Form=True&E... 9/4/2014 Map Output • • Page 2 of 2 Legend Selected Features F f Township Lines / Major Roads /� Parcels-H County Zoning MPR.SF Tracts Rural Rasdentut 1:5 Rural Rasdentul 1:10 Rural Resident of 1:20 M PR:Sing le Family ■ M PR:Mundamrry M PR•Resort Complex Parks and Ramat on ■ MPR-Open Space Rural Forest Commercial Forest In hold mg Forest Ileary Industrial Anoon CPF ■ MPR-Village Canter El AP 1:20 . Rural Village Conte. ■ Resou roe Based Ind. L rg hi industrial N PR-Recreation Waste Mgnd LPF LPM Ll'C ■ Crasaroads-GC ■ Crossmads-CC ■ Crossroads.NC ■ AL 1:20 ® UGA-Urban Commercial UGA:Urban Light Indust nal UGA MDR UGA-II DR UGA-Public UGA-LBR UGA•Visnor Oriented Commercial MPR-BRN Brannon C F 50 M R LO Commemal Fore- A-M moral Revlon use Overlay • FOR INFORMATIONAL PURPOSES ONLY- Jefferson County does not attest to the accuracy of the data contained herein and makes no warranty with respect to its correctness or validity. Data contained in this map is limited by the method and accuracy of its collection. 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