HomeMy WebLinkAboutstamped_005 Shoreline Supplemental ApplicationSupplemental Shoreline Application Page 1 of 2
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.jefferson.wa.us/communitydevelopment
E-mail: dcd@co.jefferson.wa.us
SUPPLEMENTAL APPLICATION
SHORELINE DEVELOPMENT
A completed application form is a requirement of submittal. Include “N/A” in spaces that do not apply.
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 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 making any issued permit null and void.
Owner Signature: Date: _________
Print Name:
MLA # Case #
Application Type (select one):
Statement of Exemption:
See Examples on back side
of application
Variance* Substantial Development*
Conditional Use (administrative)* Conditional Use (discretionary)*
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 #: 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/development: feet
Describe the proposed property use:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SCAN ME
PRE2021-00010
921084011; 921084010 Oak Bay/Kilisut Harbor
Andrew Nordstrom
Cabins and main lodge were installed in the early 1970s, or earlier, and are in disrepair.
Proposed property use is the same as existing usage, with improvements and upgrades to the onsite septic system including new sewer piping, cabin internal
remodeling, main lodge remodeling, and the addition of two glamping tents, a sauna, a parking lot, and landscaping. The entryways of two waterfront
cabins are proposed to be shifted and portions of the internal gravel access paths will be removed. The property will continue to be used as a resort.
4 4
4
4
Existing property usage is resort. Cabins on the property have been for rent on short term basis.
closest structure ~40
DocuSign Envelope ID: A95D0A37-EAEF-467D-A246-E698B96FFFAA
Andrew Nordstrom
8/5/2021
Supplemental Shoreline Application Page 2 of 2
These activities require a formal statement of Exemption issued by Jefferson County.
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 and/or 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.
18.25.560 Exemptions listed – This is a summary from JCC18.25.560, 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.
OFFICE USE ONLY
Shoreline Development Permit Fees
Type I Exemption ($679.00)
Type II Conditional Use – Administrative ($1,552.00)
Type II Conditional Use – Discretionary ($1,552.00)
Type III Substantial Development ($2,425.00)
Type III Variance ($2,037.00)
Notice of Application; All type II and III ($149.00)
Notice of Hearing; All type III ($149.00)
Notice Board; All type II and III ($12.00)
Scan ($24.00)
SEPA; if required per CAM or PRE ($970.00)
Hearing Examiner; if required per CAM or PRE ($1,298.44)
Subtotal
Technology Fee – 5%
Total Fees* $
*Additional fees may apply.
DocuSign Envelope ID: A95D0A37-EAEF-467D-A246-E698B96FFFAA