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HomeMy WebLinkAboutLog Item 1JEFFEI: ON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street · Port Townsend · Washington 9836'8 360/379-4450 · 8001831-2678 · 360/379-4451 Fax www.co.jefferson.wa, us/commdevelopment Master Land Use Permit Application Form PROPERTY INFORMATION Tax Parcel Number: ~ r~ ITl D ~ Subdivision Name: Property Size: Site Address and/or Directions to Property: DEPT. OF COMMUNITY 0EVELOPMEN1 Lot Number: Existing Use of Property: [~-'~t 1;) ~.e,.t ~ ~, ~_. APPLICANT & OWNER IINFORMA TION Applicant (if applicable): LJ-~,v~t"~."J ~ O ~,JL-~.~J ~C3 Address: ~~ ~O ~AI~ ~~ (~O~D city: P~ ~~~,~ ~ ,, stamina Zip Code: Applicant's Signature: ~~~ ~ ~ -- - ~ '~ ~vv' v~ Property Owner(s) of Record: Telephone: (~ ~ ~ ~) Email Address Telephone: Address: City: State: Zip Code: Email Address I acknowledge that the applicant above is applying for a building permit on my property. Owne r,s s;g natu re :)K(~,(C~~..~Xkk .~kT I hereby designpte A~..~O/,..tr~ ~_.. '",~~ (PRdPERW '~ER SIG~~~ ' -v -- I to act as my agent in matters relating to this application for permit(s). (DATE) DESCRIPTION OF PROPOSED USE OR ACTIVITY (include separate sheets as necessary) ['I'HIS SECTION FOR OFFICE USE ONLY] Refer to the specific sections of the UDC referenced below for more information and further requirements: An asterisk (*) indicates that a supplemental application or questionnaire may be required. Type I Permits MASTER LAND USE PERMIT,DOC REV. 01103/2002 [] Septic Permit/Evaluation of Existing System (EES) [] Building/Demolition Permit [] Allowed "Yes" Use Consistency Analysis [] Home Business [] Stormwater Management * [] Road Access* Boundary Line Adjustment* [] Minor PRRDAmendments [] Sign Permit* [] Site Plan Approval Advance Determination (SPAAD) [] Shoreline Master Program Exemption/Permit Revisions [] Temporary Use (based on use may be Typ~I!~_r~T~IL~)* Page~.~of Refer to: UDC Section 6.4.1 and Chapter 8.15 JCC UDC Section 3.2.1 and Table 3-1 UDC Section 3.2.1 and Table 3-1 Table 3-1 and UDC Section 4.20 UDC Section 6.7 UDC SectiOn 6.8 UDC Section 7.2 UDC Section 3.6.13.15 UDC Section 6.15 UDC Section 8.7 UDC Section. 5 UDC Sections 4.38 and 4.39 (OVER) Twe II Permits [] Discretionary "D" or Unnamed Use Classification [] Cottage Industry [] Short Plat, Preliminary and Final* [] Binding Site Plan* [] Conditional (Administrative) "C(a)" Use [] Conditional (Discretionary) "C(d)" Use [] vanance, [] Wireless Telecommunication E] Shoreline SubStantial .DevelOpment (Primary Use) [] Forest Practices Act/Release of Six-Year Moratorium for Single- Family Residence [] Appeal Refer to: . UDC Sections 3.2.1, 3.2.2 and Table 3-1 UDC Section 7.3 and Table 3-1 UDC Section 7.3 UDC Section 7.5 UDC Table 3-1 and Section 8.8 UDC Table 3-1 and Section 8.8 (Discretionary Permit Review Process Determined by Administrator) UDC Section 8.9 Ordinance 06-0712-99 (UDC Appendix C) UDC Section 5 UDC Section 4.16.5(c) UDC Section 8.4.2 SEPA 8.10.12(b) Type III Permits [] [] [] [] [] [] [] [] [] [] [] Conditional "C" Use Long Plat, Preliminary* Planned Rural Residential Development Preliminary Approval (PRRD) and Major Amendments* Plat Vacation/Alteration Variance, Major* Reasonable Economic Use Variance* Wireless Telecommunication Shoreline Management Substantial Development, Secondary Use* Shoreline Management Conditional Use* Shoreline Management Variance* Appeal UDC Section 8.8 . · UDC Section 7.4 UDC 'Section 3.6· 13 (must be in conjunction with an underlying land division application) UDC Section 7.1.3(d) UDC Section 8.9 UDC Section 3.6.4(h). Ordinance 06-0712-99 UDC Appendix C UDC Section 5 UDC Section 5 UDC Section 5 . UDC Section 8.4.3 SEPA 8.10.12 (c) Type IV Permits [] Long Plat, Final [] PRRD, Final Type V Permits [] Special Use (Essential Public Facilities) [] Jefferson County Comprehensive Plan/UDC/Land Use District Map Amendment* [] Jefferson County Shoreline Master Program Amendment* [] Appeal of SEPA UDC Section UDC Section UDC Section UDC Section UDC Section UDC Section Other Local, State or Federal Permits 7.4 · ~ / - . 13/i i I AY 13 2002 8.1 ~l~,.(d) t [] Please identify any other local, state or federal 'permits required for this proposal, if known: ACKNOWLEDGEMENTS [PLEASE NOTE THAT TWO SIGNATURES ARE REQUIRED] By signing the application form, the applicant/owner attests that the information provided herein is true and correct t° the best of their knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property. Any material falsehood or any omission of a material fact made by the applicant/owner 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 required later inspections. This right of entry shall expire when the County (through the Administrator or the Administrator's representative~) concludes the application has complied with all applicable laws and regulations. Access and right of entry to the-~pplicant's(~Pri~t~ertY sll~'!!l I:~'\requested and shall °ccur °nly during regular business h°urs' (PRO--P~RTY O"~R OR ;U;HOI~IZED REPRESENTATIVE SIGNATURE) (DATE) 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 App!icant acknowledges that he, she or it holds individual and non-transferable responsibility for adhering to and complying with the ESA.t~The Applicant bas read ~i$"d, isclaimer and signs and dates it _be~w,,~.. ~ (PRO;ERTY ~ O'eR AUTHORIZED REPRESENTATIVE SIGNATU~ (DATE) ~,. JEFFEI: ON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street · Port Townsend · Washington 98368 360/379-4450 · 8001831-2678 · 360/379-4451 Fax www.co.jefferson.wa.us/commdevelopment Master Land Use Permit Application Checklist This packet contains materials to help you make application for permits and approvals under the Unified Development Code. The list below details those documents that constitute a complete application. Yes No NIA ~ E] MASTER LAND USE PERMIT.DOC Pre-Application Conference held. If the projec~ application is made for a Type II or Type III permit or a Type I application proposing impervious surfaces of ten thousand (10,000) square feet or more and/or non-single family structures of five thousand (5,000) square feet or more a conference, is required. Otherwise, this does not apply. A completed Master Land Use Permit Application Form (attached) This application must be signed by the property owner(s) and the agent, if an authorized agent is designated. The applicable fee, as set forth in the Jefferson County Fee Ordinance (see attached). J~ ! ~,~ ~ A Site Plan. All site plans shall be drawn with a straight edge and features shali be to scale. For Residential Applications - A site plan printed on 11"x17" (or smaller) paper with a graphic scale of 1"=50' for parcelsover one acre in area and 1"=25' for parcels under one acre showing the following. [] North arrow [] Title block with the project name and address, drawing title, tax parcel number, and the name/address/phone of the person preparing the drawing. [] All property boundaries, total parcel acreage or square footage dimensions, and the land use on adjoining parcels [] Building footprint and square footage for all proposed and existing structures [for Site Plan Approval Advance Determination (SPAAD) applications show buildable area rather building footprint] [] Environmentally sensitive areas such as ravines, seasonal creeks, bodies of water, wetlands, steep slopes, etc. [] On-site septic system location or sewer lines (existing or proposed) [] Well location or water lines [] Impervious surfaces such as driveways or patios [] Setback distances from property boundaries to struciures, distance between structures, and distance from structures to environmentally sensitive areas such as wetlands, shorelines, steep banks, etc. [] Location of any easements and encumbrances such as utility or access easements [] Method and location of stormwater disposal facilitates such as drainage swales, tightlines, dry wells, curtain drains, etc. [] For applications on marine or river shorelines show ordinary high water mark, top of banks and height of banks For Commercial, Industrial, Multifamily and Small-scale Recreational and Tourist Uses as listed in Table 3-1 - A site plan prepared by a licensed civil engineer, architect, or landscape architect containing the following information in addition to the general information required above (in these instances, site plans may be printed on larger paper). [] All existing and proposed development or use areas. [] Existing structures and significant features on the subject property and on adjacent properties. [] Property lines, adjoining streets, and immediately adjoining properties and their ownership. [] The layout of an internal vehicular and pedestrian circulation system, including location and dimensions of existing and proposed improvements on public rights-of-way such as roads, sidewalks, and curbs. [] Corner grades and existing contours of topography at five-foot contour intervals. [] Existing and proposed grades and volume and disposition of excavated material, if applicable [] Natural drainage direction and storm drainage facilities and improvements. [] Locations of all existing and proposed utility connections [] Parking spaces and driveways. [] Proposed landscaping. A State Environmental Policy Act (SEPA) checklist (unless project is SEPA exempt) Evidence of available and adequate water supply, if applicable, as required by the Jefferson County Department of Health and the Coordinated Water System Plan. Evidence of sewer availability, septic approval, or septic suitability, if applicable, as required by the Jefferson County Department of Health for wastewater disposal. Supplemental application sheets, if applicable. LOG . Page of DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street. Port Townsend · Washington 98368 360/379-4450 · 800/831-2678 · 360/379-4451 Fax · · DEPT f;:: f:©MMUNI'¥Y OEVE~_"':~ Boundary Line Adjustment (BLA) Supplemental Application PROJECT/APPLICANT NAME; ~A~ ~ ~ o ~ L. ~-~-~ 0 Submittal Requirements completed Master Land Use Application. Representative authorization is required if application is not signed by owner. ~, Boundary Line Adjustment application fee, as set forth in the Jefferson County Fee Ordinance, as amended. ~. Three copies of a clean and legible drawing sdtable for recording showing the following: a. The proposed lines for all affected lots, tracts, or parcels, indicated by bold solid lines; b. The existing lot, tract or parcel lines proposed to be changed, indicated by light broken lines; c. The intended future use of the adjusted lots, tracts or parcels; d. The location and dimensions of ali structures/improvements existing upon the affected lots, tracts or' Parcels and the distance between each such structure/improvement and the proposed boundary lines, with structures proposed to be removed from the site depicted with broken lines, and structures to remain on the site depicted with solid lines; e. The original legal description of the entire property together with new separate legal descriptions for each lot, tract or parcel, labeling them each as existing parcel A, existing parcel B, revised parCel A, revised parcel B, etc.; f. A north arrow indication and scale; g. All assessor's tax parcel numbers for the affected lots, tracts or parcels; h. The location of the property as to quarter/quarter section; i. ~ The locatiOn and dimensions of any easements within or adjacent to any affected lots, tracts or parcels; . j. The lOcation, right-of-way widths, pavement widths and names of all existing or platted streets or roads, whether public or pdvate, and other public ways Within. Or adjacent to the affected lots, tracts or parcels; k. The area~ ~,rn~n~ of ea,ch~10t, tract or parcel, following the proposed adjustment; I. The existing, and if applicable, propd~sed future method of sewage disposal for each affected lot, tract or parcel, including 'the lo,Cation and dimensions.of~and prbposed septic drainfield; · mo The location of all existing a,nd pr0po~,ed water and storm drainage facilities; and n. i.]:ti~ ~pproximat'e4ocation ariel' ~t'~h~·'~3f any environmentally sensitive areas (ESAs), including any flood hazard areas lying within the existing or revised parcel boundaries. (Maps are available for review from the Department of Community Development.) copy of any Covenants, Conditions and Restrictions (CC&Rs), deed restrictions, or planned rural residential development (PRRD) agreements pertaining to or affecting the property. If an individual sePtic system is proposed (i.e., as opposed to connection to either a community drainfield or municipal sewer system), written verification from the Jefferson County Department of Environmental Health that the lots, tracts, parcels or sites, as each would exist after the boundary line adjustment, are adequate to accommodate an on-site sewage disposal system. 1. Please provide a brief description of the purpose of the proposed boundary line adjustment. L©C BLAAPP. DOC REV. 10/04/2001 Page 1 2. Please provide Existing Legal Descriptions of all affected lots, tracts or parcels. (Attach additional sheets, if necessary.) ParcelA: ~-'~_{-- ( I~..-- Parcel C: Parcel D: : , 3. Please provide Proposed Legal Descriptions of all affected lots, tracts or parcels. (Attach additional sheets if necessary.) Parcel A: Parcel B: -  ',' Parcel C: Par. ID: __~:r ~. ut- [JUMMUNITY DEVELOPMENT _ , 4. All owners of the subject properties must sign the application below to signify agreement to the proposed bOundary line adjustment. The applicants hereby certify that all of the above statements are true and the plot plan Provides an accurate representation of the proposed boundary line adjustment, and the applicants hereby acknowledge that any permit issued on this aj3plicafion maycl~ revoked if any such statement is found to be false. a. ~k~~ .~X~X~j~~.. Date: c. BLAAPP,DOC REV. 10/04/2001 page c Page 2