HomeMy WebLinkAboutBLD2022-00585-09G- SHORELINE DEVELOPMENTSupplemental 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
9-29-2022
RECEIVED BY DCD 12/5/2022
002352009 Discovery Bay
Shaheed & Julia Khan
Single family residence and detached garage
Shaheed Khan
4
4
4
2421 Old Gardiner Road - Residential house and garage
165
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 DCD017 ($714.00)
Type II Conditional Use – Administrative DCD017 ($1,122.00)
Type II Conditional Use – Discretionary DCD017 ($1,632.00)
Type III Substantial Development DCD017 ($2,550.00)
Type III Variance DCD017 ($2,142.00)
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 ($25.50)
SEPA; if required per CAM or PRE DCD021 ($1,020.00)
Hearing Examiner if required CAM or PRE DCD002 ($1,298.44)
Subtotal
Technology Fee DCD003 – 5%
Total Fees* $
*Additional fees may apply.
RECEIVED BY DCD 12/5/2022
25.5