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Home My WebLink About2- Permit and Supplemental Shoreline Application with Written RequestK ar I Pndueom H CG Norclia,v, Lon qMS the fv bu'l 16 o- 2- bejroDro kvw- t -b- -.rep � - - - - t''Uioo, -7'be hevue- CX 1:5+1 ril bu' bt- tamvg,4181�-, -to cLrOLJ VI Cl LP5- no _m4:"46n ,5 wt�h - 4v 5hv re. / fie, e r Al aL/ i P q,Aai toe, peecl - 6" jhar4m e-. VcLr i aii;z, f, -e4 -Cor f -h - oh.al I up:s>� O'nq ......... 9-14V,f40C AD DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Stiect, Port Townsend, WA 98368 Tel: 360.379.4450 1 Fax: 360.379.4451 Web: �� ww,ca.jeFctson.wa.usOcos�trTiu��iyc1��IUy i E-mail: dcd 0JccfFerson.wa.0 S PPLEMENTAL APPLIC LTION SHORELINE DEVELOPMENT A completed application form is a requirement of submittal. Include "N/A" in spaces that do not apply. MLA # Case # Application Type (select one): Statement of Exemption- Variance* Substantial Development* See Examples on back side of application n Conditional Use (administrative)* Conditional Use (discretionary)* 1) Does your proposal require in water) work and/or works below ordinary high watermark? Yes [ TN [:,' ] 2) Does your pro --cal require 9 n,0'00 sq/ft or more of impervious surface and/or non -single family structures of 5,000 sq/ft or more? Yes [ ] No [ -] * If either of the boxes for 1 or 2 above are checked yes or if the permit type above has an asterisk then a re -a lication conference is Muired prior to submitting for a shoreline permit. Site Information Assessor Tax Parcel #: I _� �� Name of Body of Water: Property Owner Name(s): Project Description Describe the existing property use and condition: Proposed distance from ordinary high water mark to use/dei Describe the proposed work that requires a shoreline permit } By signing this application form, the owner/agent attests that the informa - , u11-1-FICI Ku, s true ano correct to the best of his or her knowledge. Any material falsehood or any omission of a material fact made by the owner/agent withrespect to this application packet may result in making and prmi ,rilland void. Owner Signature: `�-�r`� Date: Print Name:F'3 A e5itldx Supplemental Sliorclinc;lpplicatiun Page 1 liC''?'.°`yE. These activities require a formai statement of Exemption issued by Jefferson Counly.. Check Statement of Exemption' box on the front of this form and submit with Permit Application to apply for your Exemption Approval. 18.25.570 Statement of Exemptions (1) The administrator is hereby authorized to grant or deny requests for statements of exemption from the shoreline substantial development permit requirement for uses and developments within shorelines that are specifically listed above. Such statements shall be applied for on forms provided by the administrator. The statement shall be in writing and shall indicate the specific exemption of this program that is being applied to the development, and shall provide a summary of the administrator's analysis of the consistency of the project with this program and the Act. As appropriate, such statements of exemptions shall contain conditions andlor mitigating measures of approval to achieve consistency and compliance with the provisions of this program and Act. A denial of an exemption shall be in writing and shall identify the reason(s) for the denial. The administrator's actions on the issuance of a statement of exemption or a denial are subject to appeal pursuant to the appeal provisions in Article X of this chapter. 18.2.5.560 Exemptions listed —This is a summary from JCC18.26.560, please review the code section for detailed information regarding these exemptions. (1) Fair Market Value. (2) Maintenance and Repair. (3) Residential Bulkhead. (4) Emergency Construction. (5) Agriculture. (6) Drainage. (7) Navigation Aids. (8) Single -Family Residences. (9) Residential Docks. (10) Irrigation. (11) State Property. (12) Energy Facilities. (13) Site Exploration. (14) Noxious Weeds. (15) Watershed Restoration. (16) "Watershed restoration project" (17) "Watershed restoration plan" (18) A public or private project, the primary purpose of which is to improve fish or wildlife habitat or fish passage. 5upple1T1cntal Shoreline Application Page 2 of 2 �EPAR'T'N,I'F�N'I'OF'CC)NI),if[/N..f)-EVE.[,,OI'MEN7' Steps )nthe Permit Process: 'Reviewapp|icabonchecNisttoensureaUinfornnaboniacomp|etedpriortosubmittingapp|icat 'Makesuresepdchasbeenapp|iedforandwateravai|abiUh/hasbeenproven, ^v� -Make an appointment to meet with the Permit Technician by calling 360-379-4450. -This is not standalone application; itmust be accompanied by a project specific supplprnerto|app!ifat)om. Fees will be co||ected at intake. Additional fees may apply after review and payment is required before permit is issued. For Department Use Only Building Permit # Related Application #s: MLA 9 Site Information Assessor Tax Parcal Number- 0 47 4 - Site Address and/or Directions to Property: Access (name of street(s)) from whic access will be gained: Present use of property: -!S( (�A tx vtm( 110 Description of Work (include proposed uses): Wy77-/ 6/x1W/41(-XC Wastewater - Sewage Disposal This property is served by Port Townsend or Port Ludlow sewer SY YES N 0 If not served by sewer identified above, identify type of s w Type of Sewage System Serving Property� Septic Se p ti c Perrn if Community Septic N a m e o f, �'V'js t'e m: Case #.- Are other residences connected to the septi�c sy�tem? Additions or repairs to sewage system: Is it complete orpartial system installation, `/ Complete ' ~^�' Partial Has a reserve drainfield been designated? Yes No Date of Last Operations & Maintenance check: Attach last report to application Describe or attach any drainfield easements, covenants or notices on title, which may impact the property� The authorized agent/representative is the primary contact for all project -related questions and correspondence. The County will mail / e-mail requests and information about the application to the authorized agent/representative and will copy (cc) the owner noted below. The authorized agent/representative is responsible For communicating the information to all parties involved with the application. It is the responsibility of the authorized agent/representative and owner to ensure their mailbox accepts County email (i.e., County email is not blocked or sent to Junk mail"), A,pplircan't/Propfer'ty Owner Information id. Property Owner, Name: cc.✓ 4u(\LY62V:�_)O Address:(.� ✓►_ " °� `` crtA Phone #: ZS ��:.t - Ice E-mail Address: Please tact Authorized Agent/Representative with project info. (select only one). Property ®caner Signature:.' JA / Date: Mote: For projects with multiple owners, attach a separate sheet with each owner(s) information and signatures. I Applicant: Authorized i'�gentlReprese'nt.athie(if other than owner) Name: G ►Ca o�� P C�1 i �=� E Address: LCC( 4 rYll .�k7`t Phone r#: CpLj _ c( E-mail Address: \/O WO OX et eG'i..0 lv e , e� •� Professional. Is this an Authorized Agent/Representa'tive'for this project? NO YES Engineer ✓ Architect Surveyor Contractor Consultant game: L—L.— Vk-k L) e -V!_e_ License # `t-(') I -2- Address: ) � .. t 2 -TL VV F v 8 4,3e 0UkO c -S CAA `2 E Phone #: CT— I } (z,(, E-mail Address: Professional. Is this an Authorized Agent/Representative for, this project! AJO YES Engineer Architect Surveyor Contractor Consultant Name: License # Address: Phone #: E-mail Address. Provfessiional: Is this an Authorized Agent/ esentative for this project?: NO `(ES Engineer Architect Sur Contractnf: t + -... Consultant Name: License #4 �„' ... Address: Phone #: +} ress: Lr i By signing this application form, the owner/agent attests the infor vided herein, an{t>'ir, any attr6ments, is true and correct to the best of his or her knowledge. Any material fa d or a ion of a material fact�n alae by the owner/agent with respect to this application packet may result in making any issue mit nu and void. I further agree to that all activities I intend to undertake or complete 'satiated with this permit will be performed in compliance with all applicable federal, state and county laws and regulations and I agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and any required later inspections. Applicant may request notice of the C unty's intent to enter upon the property for visits related to this application and subsequent permit issuance. Signature: � &IL, <........: r.. ... Print Name: �� lr r'�� Date: � �2.