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JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street. Port Townsend' Washington 98368
360/379-4450' 800/831-2678 ' 360/379-4451 Fax
MAR 2. 4 200S
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Pre-Application Conference
The Jefferson County Unified Development Code (UDC) requires that before an application is made for all Type II and
Type III project applications and Type I applications proposing impervious surfaces of ten thousand (10,000) square feet
or more andlor non-single family structures of five thousand (5,000) square feet or more, a pre-application consultation
must be held. The consultation includes preliminary review and administrative assistance. This service does not include
extensive field inspection or correspondence. Pre-application consultation does not limit subsequent administrative
review.
At the conference, Department of Community Development personnel shall provide the applicant with:
(1) A list of the requirements for a completed application;
(2) A general summary of the procedures to be used to process the application;
(3) The references to relevant code provisions or development standards that may apply to the approval of the
application; and
(4) A list of any applicable hourly review fees that may be charged by one or more County agencies upon the
filing of a project permit application with the County.
Discussions at the conference or the information provided by the staff shall not bind or prohibit the County's future
application or enforcement of all applicable laws and regulations. No statements or assurances made by County
representatives shall in any way relieve the applicant of his or her duty to submit an application consistent with all relevant
requirements of County, state and federal codes, laws, regulations and land use plans.
NAME: P JIo\ l~ Un\..(
MAILING ADDRESS: P-o P:>0~
TELEPHONE: (HOME) 34.> () ~ )(S- &""yo 0
REPRESENTATIVE: '-.J {M Dayl..U: e It..
MAILING ADDRESS: 6 ~
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(WORK) cS
TELEPHONE: (HOME)
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(WORK)
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1. . Please answer all questions on this form completely.
2. Attach a sketch of the Conceptual Design for the proposed use or activity, showing the following information:
a. Vicinity sketch; M4(~
b. North arrow and scale;
c. Property boundaries and identification of land uses on adjacent properties;
d. Means of ingress and egress;
e. Property/lot drainage;
f. Possible locations of sewage disposal and water supply systems;
g. Location of utility easements; and
h. Proposed location of buildings, including setbacks to property boundaries.
3. Attach payment of the applicable fee, as set forth in the Jefferson County Fee Ordinance.
PRE-APP CONFERENCEDOC REV. 0412212003
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Property Description
General Location: I'U a /t1l{jWJ~/vE
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MAR 2 4 2005
Legal Description (from Property Tax Statement):
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9-Digit Parcel Number (from Property Tax Statement):
Total Acreage: N/;/t Zone: Al/~
% Lot Coverage:
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Applicant:
DOwner
D Contract Purchaser
D Lessee
D Other
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Project Description
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Property Owner (name and mailing address): AJ:.
Standard Disclosure
Information provided to a prospective applicant during the pre-application consultation is based on County regulations in effect at the
time of the pre-application consultation. Revised or new County requlations could affect a future development application. A pre-
application consultation does not vest a future development application.
By signing the application form, the applicant/owner attests that the infonnation provided herein is true and correct to 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 hannless Jeff~rson 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 pennit.
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 representatives) concludes the application has complied with all applicable laws and regulations.
A~. and right of .nt'1'o ''l")'ppucant's ",operty shall be reqU""e.d and shal.1 occur only during regular business hours.
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(SIGNAlUR ) M..t(,Vl...tLile if..- (DATE)
I hereby designate 0~6S G P a.Jl../LlA. I P e: to act as my agent in matters related to this pre-application
conference. /1
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(~~ER SIGNATURE) (DATE)
PRE-APP CONFERENCE. DOC REV. 04/22/2003
LOG \TEM
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