HomeMy WebLinkAbout02- SUPPLEMENTAL APPPage 5 of 6
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
BOUNDARY LINE ADJUSTMENT (BLA)
MLA # PROJECT/APPLICANT NAME:
Submittal Requirements
1.Please provide a brief description of the purpose of the proposed boundary line adjustment.
2. Please provide Existing Legal Descriptions of all affected lots, tracts or parcels. (Attach additional sheets, if necessary.)
Parcel A:
Parcel B:
Parcel C:
Parcel D:
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3.Please provide Proposed Legal Descriptions of all affected lots, tracts or parcels. (Attach additional sheets if necessary.)
Parcel A:
Parcel B:
Parcel C:
Parcel D:
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 application may be revoked
if any such statement is found to be false.
a. Date:
b. Date:
c. Date:
d. Date:
OFFICE USE ONLY
Boundary Line Adjustment Permit Fees
Land Use Review DCD016 $918.00
Environmental Health – BLA Base Fee (no lots included) $232.00
Environmental Health – Per Lot Fee (103.00/lot)
Scan Fee DCD022 $25.50
Technology Fee – 5% DCD003
Subtotal
Total Fees* $
*Additional fees may apply.
Seo attached Delaration of Single Lots Upon Bourdary Une Adjustment
See attached Declaration of Single Lots Upon Boundary Une Adjustment
Parcel B:
Parcel C:
Parcel D:
e Please provide proposed LeBal Descriptions ofall affected
Parcel A:
lots, tracts or parcels. {Attach additional sheets if necessary,)
the application below to signifli agreement to the proposed boundary line adjustment.
above statements are true and the plot plan provides an accurate representation of theapplicants hereby acknowledge that any permit issued on this appltcation;;y; rcvoked
{^ro -/W 1-?-
4.
a,
b.
c.
d.
All owners of the subject properties must sign
The applicants hereby certifu that all of the
proposed boundary line adjustment, and the
ff any such statemem ls found to be false.
Lic.t w*,ir13vr,,1
Date:
Date:
Date:
Date:
*Additional fees may apply
Page I of 6
I
USE
Line Fees
Use Review DCD016
Health -Base lots
Environmental - Per Fee
Fee
Fee - SYo DCD003
Subtotal
Total Fees*