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. -EF'FERSON COUNTY
SUBDI V2 S 2 C) EXE ME'TI ON AP'PL2 C Aka'2 ON
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The Jefferfson County Subdivision Ordinance exempts certain proposals from
the platting requirements of the Washington State Plats-Subdivisions-
Dedications Act (RCW 58.17). To qualify for an exemption, the proposal must
be reviewed and approved by the Jefferson County Planning and Building
Department.
Please answer the following questions completely, using ink or a typewriter.
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APPLICANT: f c 1 `1 /l a 0 ' •� Y' u S t� - 4
ADDRESS: /�O-}L O S f 7--
TELEPHONE: (home) /U a 'i -c (business)
REPRESENTATIVE/CONTACT: "4 c h a/O( l,.r/a a WI
ADDRESS: 'Z / 5 5- C
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TELEPHONE: (home) 3 4'S 5 P 6- (business) Sa —
FROP'ERTY AND
P'ROFOSAL DE E CR2 1:"T2 ON
•
GENERAL LOCATION: y r �� 5 1-v 3-4 C /o
i-4/ 7 e E I
LEGAL(S) (identify each affected property):
• Owner: hi ( Jr L /4 h of S T7 K S �r l�� , Lt/a--,71
Address: ie. O', Aa--``� 6' a C
Tax Parcel Number (9 digits): 0 0 / 1 ' -f a / /
Real Property Description: ' / 8 7- 3 d / w
"2- tt) S F y
• Owner:
Address:
Tax Parcel Number (9 digits):
Real Property Description:
Application Received 61 .
No determination of a sul, •t nti3 I
complete.application has Wen reale,
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PROPOSED ACTION: I O c-- I v {' S A- C ✓ e S
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S I TE PLAN
A site plan must accompany the exemption request. It shall be no larger
than 11 by 17 inches, to scale, and suitable for copying. It shall illustrate
and identify the following features:
1. North arrow and scale.
2. Existing and proposed property boundaries; identify lengths.
3. Property improvements (well, septic systems, house, etc.).
4. Parcel ownership.
5. Roads serving the property.
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ACKNOWLEDGEMENT
I hereby declare that the information provided in this application and all
attached material is true and correct to the best of my knowledge.
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(authorized signature) (date)
OF'VICE USE ONLY
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EXEMPTION TYPE: _ \.) AQ e APPLICABLE ORDINANCE SUBSECTION: ZpL10 (,3
CIAPPROVED 0 DISAPPROVED
MMENTS:
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1,RESPONSIBLE OFFICIAL: GC9 LKX
TITLE ,l, �kP /, ,tiA42u1JJ(di)
DATE: 7 c: ./9c -
COPIES: M Applicant 0 Public Works Department
: �Representative 0 Health Department
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