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• • /�4� ��, JEFFERSON.UNTY •
I akiiii`� DEPARTMENT OF COMMUNITY QEVELOPMENT ' : ;1
621 Sheridan Street• Port Townsend •Washington 98 68
360/379-4450 • 360/379-4451 Fax
4 0 www.co.jefferson.wa.us/commdevelopment r,
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Master Permit Application MLA: OR- Doc\
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Project Description inclYde s parate 'sheets as nece sary): •
9`s) a c �z via L>� 'f F w ti3O p l v nib inc-
Tax Parcel Number. 0 I I (0 3C0 (4, Property Size:2f 7 7 `j7.)• (acres/square feet)
Site Address and/or Directions to Property:
.3 0 ' C Ac . c hole,le, R( _.P'l mh'1 lit GtC by
Property Owner(s)of Record: 1 I ak' II- jC T_ii/1
Telephone:("3 490) 7 32. (-1 j -]1-1 Fax:
��� � `, email:
Mailing Address: J t/G, c- Ova
Applicant/Agent(if different from owner): R.e-kx L C tJ� . 1 )\ yl cti-' Len-, Y'.ty^
, _ ,
Telephone(r'�zS )l`f 3 -- /S�J E Fax c l'7 2 S)7 YZ-'}3.7 � email: rinl ct�pcyJr4 i (71C.M'". I
Mailing Address:1�� 11")Y)- L'J fl ' to- 1
What kind of Permit?(Check each box that applies
Auilding CI 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 0 Modular —❑Discretionary"D"or Unnamed Use Classification
❑ Commercial* ❑Special Use(Essential Public Facilities)"
❑ Change of Use ❑Boundary Line Adjustment
❑ Address 0 Road Approach ❑Short Plat**
❑ Home Business 0 Cottage Industry 0 Binding Site Plan**
❑Propane ❑Long Plat"
0 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)' 0 Shoreline Management Substantial Development**
❑Temporary Use 0 Shoreline Management Variance
❑Wireless Telecommunication* 0 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:
DE G TION OF AGENT
I hereby designate &('(/i iv CJ' 1 C1) i ' 7'o act as my agent in matters relating to this application for permit(s).
f
OWNER SIGNATUR /!?/./le Date: —
By signing this application form,the owner/ag t ests that the informati provided herein,and in any attachments,is true and correct to the best of
his,her or its knowledge. Any material falseho 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 later inspections. Staffs access and ri ht of entry will be assumed unless the applicant informs the County in writing at the
time of the application that he or wan r'or notice.
Signature: Date: G
The action or actions Applicant will undert as a result of the issuance of permit may negatively impact upon one or more threatened or
endangered species and could lead to a ential"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 responsi i for ei g to complying with the ESA. The Applicant has read this d• aimer and signs and dates it below.
Signatur . IGC-`c+1. 3 Date: / - /j ��
G:\PennitCcntcr\###FORMS###\DRD FORMS\Master Permit Application 5-29-08.doc
07/22/2009 08:45 3603794451 JEFF CO PERMITCENTER PAGE 02/03
• •
RECEIVED
The AI¢rter of If*tftih�hmrtl ROA r Jul,-
h+rnbY of i Goners]
]CO are lots for the copes pamwl+eferpr�cea here n ewe that are rat tensed
they wrtfl Ix ar�.umhg IlM lDepDR4t'JRY of hi dafreral Contrsctnt for the ptnp/iAC+Q �o�UcMa aired end
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t1etGAtso t~r pi . t .
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don n fad Proposed: _LJy(. 1 Beek ❑Comrotaa7Y System
h AMcredon/Remodel 0 Concrete Told: Haight' indlvi 0 Repntr o S P Pernik du�System
n pary1OP1on n der rrr
Sedrooa: Supply:
Water
Pea xitgno selberar ❑ Private well " o Marty
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N r of -r,Lelel Pr � roust an o
the tWlwino it;1 -E x,' J�
Corm& Proposed: Number of
Number of Perk>rrg Simms:,
nrsa (Mottos oMmara,tenants.empfogpec,etc) Current Proposed
IHC Occupfutcy: IBC Typo Of come alert Wil you have Food Service?i�es,1 No
K! J A.IN Tt1Ak antgar Appfpncr-lnslallatiplipertnlC.rnsrk;11 haete helpyi that avow J U 2 7 Z,D 3
t Underground Tank 1 Alone Qrarmd Tank Sim ofPropane Tank
I Heat Stove t Conk Slow T WOodreove 1 Fireplace trued 1 Hot Wader Tank 1 Print Siam 1 Other •
.�helrxl MrFallotl n n MlainufraoW* u Mob Home? )(co 1 No
When apphdog fora mow to Imand a poopano tank you must Rise Salm&a&Ho plan MroWhrp RP of the
ims,tank ,flan and�ttn;n»from ere propona tank!e alrpr vperty Nears,bu aepdcby +n..Rr
Are � ov q � T AC 0
ctnennt ► ormAma.
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-2"floor Ifeatro ^�-- --- iterN .t rw i
'1 .••�r.,u: t Corelt9h O4*Reulct'c _'�1 I2
Other!footed tiµ 't--41:;rh Base lee. • (Jt/ —....
tented Best-merit •
r—f i;Z.,r W, r�
:1 G lr Flan chock fee: carp.q 1
tkArLvth tl tlr+rerrlrrrt <�.{ ,,Ls
Stale Stec/urge fee
Other Unhcaud .`Lt.:11:171, Pot%Aar Review foe: I
to =16ernoe/Cerot , ': 4` SlSTOTAL f)1 ! r067, 9 fir,,, dA•
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