HomeMy WebLinkAbout02 - SupplementalSON DEPARTMENT OF COMMUNITY DEVELOPMENT
�� OG 621 Sheridan Street, Port Townsend, Wig. 98368
W Tel:360.379.4450 1 Fax:360.379.4451
-C Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcdnco.jefferson.wa.us
r N O�O� SUPPLEMENTAL APPLICATION
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-
See Examples on back side
F-1Variance*
❑ Substantial Development*
y Conditional Use (administrative)*
IConditional Use (discretionary)*
of application
1) Does your proposal require in water work and/or works below ordinary high water mark? Yes No
2) Does your proposal require 10,000 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 pre -application
conference is required prior to submitting for a shoreline permit.
Site Information
Assessor Tax Parcel #:
q 4W6 Name of Body of Water:
Lar'r lA W
Property OwnerName(s):
Project Description
Describe the existing property use and condition:
S-In, 1e_ 5�t1Ll aIfae-keoA
Cu)17T'3w� Gynd l)h' '00 iS uAl C&y-eA or_.
Proposed distance from ordinary high water mark to use/development:
feet
Describe the proposed work that requires a shoreline permit or permit exemption:
pemoae_� XtS (�Caml��ne.
�b �oo� runts a
r 0 nt ►Yl L e' `A
v not
S hnru expA lnsi d . 1 ACAU A t n kyils b r oww
is a. in"
By signing this application form, the owner/agent attests that We information provided herein, and in any attachments, is true and correct to the
best of his or her 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 ma�'nanysued pe mit ull and v id.
Owner Signature: Date:
Print Name: 13�
S=_irplemcntal SIlowliv' Appjjcatino Page 1 of