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4 SITE PLAN
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��.�SON c0� JEFFERSON•UNTY • I � �.� �
�" DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street• Port Townsend •Washington 98368 pn
"I! — 6 e^^-,
360/379-4450 • 360/379-4451 Fax
1q O' www.co.jefferson.wa.us/commdevelopment
, . _ IttfiSIO 1:(11ININCil
Master Permit Application MLA.
Project Description(include separate sheets as necessary):
' a0 >c YO 7wo •sh,127. e,v62/zs,4&,10
Tax Parcel Property
Number: / ( �OO Zo3 Size: 7610 5/_ '-,- (acres/square feet)
Site Address and/or Directions to Property: £9 51 {3&Z," 4,%t,' liver gel- /J /� tog 9 i33 cl
Property Owner(s)of Record: /2Zcs,e( ,'_ i9dc,E;A-,x-
Telephone: cQ06- $/7- 5' ,7? Fax: email:fg�aS1-/Opni &
Mailing Address: 025/ ]3412.y i(fvn) i i€ ( f 6c-t- we9 ' 33 5- e,d,l/espe eci,Caw'.
Applicant/Agent(if different from owner):
Telephone: Fax: email:
Mailing Address:
• What kind of Permit?(Check each box that applies)
ALBuilding ❑Variance(Minor,Major or Reasonable Economic Use)
❑ Demolition Permit ❑Conditional Use[C(a),C(d),or C]**
❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification
arage Attach /Detached ❑ Special Use(Essential Public Facilities)**
0 Manufactured H ❑ Boundary Line Adjustment
❑ Modular ❑ Short Plat"
❑Commercial* ❑ Binding Site Plan"
❑Change of Use ❑ Long Plat**
❑Address [l Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments**
❑ Propane 0 Plat Vacation/Alteration**
❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions"
❑ Stormwater Management ❑ Shoreline Management Substantial Development"
❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance
0 Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium
*May require a Pre-Application Conference **Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date:
By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of
his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet
may result in this permit being null and void.
I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and
expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit.
I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application
review and any required I r ins ctions.Access and right of entry to this property shall be requested and shall occur only during regular business
hours.
Signature: 7 Li 'f TZ.i(PR 9 ) Date: 5 ..26_d
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual
and non-transfe pon ib''ty or adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: C5 c , IG_(} � s-d-7D G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc
• OWNER BUILDER STATEMENT •
The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that
they will bi
ing the responsi ility of the General Contractor for the proposed project.
Signature � Date: 5-2 5 - o 7
GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX:
( ) ( )
MAILING ADDRESS: EMAIL:
CONTRACTOR'S LICENSE WAINS
NUMBER: NUMBER
ARCHITECT/ENGINEER: PHONE ( ) FAX:( )
MAILING ADDRESS: EMAIL
Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal:
04—New g Wood E 'sting: ❑ Sewer
Li Addition ❑ Steel Pro sed: Bank ❑ Community System
❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System --
❑ Repair ❑ Masonry /) , SEP Permit# 7 9 yj�0
Bedroo s: /C Water Supply:
❑ Demolition [l Other: pp Y:
Existing: Setback: i i Private well Ll Two Party
Type of Heat: Proposed: / ❑ Public
c4/C ' Tota s, y/ ,, 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(includes owners,tenants,employees,etc) Current Proposed
IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit.mark all items below that apply:
11 Underground Tank ❑ Above ground Tank Size of Propane Tank:
I 1 Heat Stove 11 Cook Stove ❑ Woodstove Li Fireplace Insert II Hot Water Tank 11 Pellet Stove Ll 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.
Square Footage For Office Use Only E A9f. (K/k k Err.
Current Proposed Amount
Main Floor Consistency Review:
2NU Floor Base fee:
3t1 Floor 1 �9.,. +'�' 7,) Additional Section:
Mezzanine: Plan Check fee:
Heated Basement State Surcharge fee: //1 �- `
L..
i
Unheated Basementii,ifiatAilin t Pot Water Review fee: ___,_
Other Unheated c.- 911/Rd Approach fee:' 17
Garage/Carport $COd 14 '�` ^.(,t TOTAL: $ 1..7,, I, ! I
Decks Receipt Number: Iv' _} (.1
Other ,r Cash/Check Number:
ZOIC
ESTIMATED COST(REQUIRED) Date: a i (,
•Fair market value of all labor and materials foundatio 4 rm ` , t
liutials:
G:\PermitCenter\FORMS\DRD FORMS\Master Pemut Application 7-8-04.d«