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Enclosure 1 Master Permit Application"
to Marrowstone Island Permit
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JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street. Port Townsend, Washington 98368
360/379-4450, 360/379-4451 Fax
www.co.jefferson.wa.us/commdevelopment
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Master Permit Application
Project Description (include separate sheets as necessary):
IF\,' 57ALL.4- &'1/7 &P '() I
Tax Parcel.. "," l '. :\
Number: MJ;\~'-v"~w'"vl€ . $~-VV\e)
MLA:
Site Address and/or Directions to Property:
Property Owner(s) of Record: N I A-
Telephone: 3 ico :s~~.. S"BC.c
Mailing Address: P-o fux. Ct) .'1
Applicant/Agent (if different from owner):
Telephone: 1555- ~y()O
Mailing Address: p.6 \.SO)( q 2.. <1
r- fL.:,,\A.
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Nt p,. (acres/square feet)
in \lAd (Qw\ \S(cIV~-+tu" fc ~\wL/Vd':-"rStVY\e.
Fax: 3~,u ~&") S~ v,.c;--
Voa.-r l-\c--'d Leel(. \/VCt)-{,l
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Fax: 3~,s- Scr I...f ~-
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What kind of Permit? (Check each box that applies)
o Building
o Demolition Permit
o Single Family
o Garage Attached / Detached
o Manufactured Home
o Modular
o Commercial"
o Change of Use
o Address i Road Approach
o Propane
o Allowed "Yes" Use Consistency Analysis
o Stormwater Management
o Site Plan Approval Advance Determination (SPAAD) "
o Temporary Use
o Wireless Telecommunication"
o Forest Practices Act/Release of Six-Year Moratorium
" May require a Pre -Application Conference
o Variance (Minor, Major or Reasonable Economic Use)
i<l"'Conditional Use [C(a), C(d), or C] ""
o Discretionary "D" or Unnamed Use Classification
o Special Use (Essential Public Facilities)""
o Boundary Line Adjustment
o Short Plat ..
o Binding Site Plan ..
o Long Plat ..
o Planned Rural Residential Development (PRRD)/Amendments ..
o Plat Vacation/Alteration ..
o Shoreline Master Program Exemption/Permit Revisions ..
o Shoreline Management Substantial Development ..
o Shoreline Management Variance
o Comprehensive Plan/UDC/Land Use District Map Amendment
o Jefferson County Shoreline Master Program Amendment
""Requires a Pre-Application Conference
Please identify any other local, state or federal permits required for this proposal, if known:
V-o', \>~bV\.\.r' ~o l\\JAL - Y\!Y~, S^v6t c,;,;1. .. DNl2. -:11\ <\ \N. \~Hlft:
~~V\A . G T) UQ.-^ DESIGNATION OF AGENT
I hereby designate .. f:::t, -r \11 ~ . to act as my agent in matters relating to this application for permit(s),
OWNER SIGNATURE
Date: fl1 A-y~ Z.CG S'-
By signing this application orm, the owner/agent attests that the information provided herein, and in any attachments, is true and correct to the best of
his, her or it's 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 this permit being null and void,
I further agree to save, indemnify and hold harmless Jefferson 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 permit.
I further agree to pro.. vide acce. ss and rigu. f entry to Jefferson County and its employees, representatives or ag e nts for the SO.le.. purp. 0 se. of application
review and any ~d later inspe 'on ccess and right of entry to this property shall be requested and shall occur only during regular business
hours. "--_ r'\ . " --
Signature: -..j... 1../\/,- "1 Date: 27 ~vvd U~ j
The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or
endangered species and could lead to a potential "take" of an endangered species as those terms are defined in the federal law known as the
"Endangered Species Act" or "ESA." Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this
permit has been issued will not violate the ESA. Any individual, group or agency can file a lawsuit on behalf of an endangered species regarding your
action(s) ev ' ou are in co!'aE'th. the Jefferson County development code, The Applicant acknowledges that he, she or it holds individual
and non-tra er e~sponsi' /0 adhering to and complying with the ESA. The Applicant has read this disclaimer and ~igns and ~a~ it below,
Signature: ."-. I. Date: Z 7f .Apt! ( "hJZ) ,)
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All site plans shall be drawn with a straight edge and features shflb~ fa scale; ___ /
For Residential Applications - A site plan printed on 11"x 17" (orsmaller)pClP~r witha.J.. I
graphic scale of 1 "=50' for parcels over one acre in area and 1 "=25' for parcels under~
acre showing the following.
o North arrow
o Title block with the project name and address, drawing title, tax parcel number, and the name/address/phone of the person preparing
the drawing,
o All property boundaries, total parcel acreage or square footage dimensions, and the land use on adjoining parcels
o Building footprint and square footage for all proposed and existing structures [for Site Plan Approval Advance Determination (SPAAD)
applications show buildable area rather building footprint]
o Environmentally sensitive areas such as ravines, seasonal creeks, bodies of water, wetlands, steep slopes, etc,
o On-site septic system location or sewer lines (existing or proposed)
o Well location or water lines
o Impervious surfaces such as driveways or patios, Show driveways all the way to the access road, not just to the property boundary.
o Setback distances from property boundaries to structures, distance between structures, and distance from structures to
environmentally sensitive areas such as wetlands, shorelines, steep banks, etc,
o Location of any easements and encumbrances such as utility or access easements
o Method and location of stormwater disposal facilitates such as drainage swales, tightlines, dry wells, curtain drains, etc,
o For applications on marine or river shorelines show ordinary high water mark, top of banks and height of banks
For Commercial. Industrial. Multifamilv and Small-scale Recreational and Tourist
Uses as listed in Table 3-1 - A site plan prepared by a licensed civil engineer, architect, or
landscape architect containing the following information in addition to the general
information required above (in these instances, site plans may be printed on larger paper).
o All existing and proposed development or use areas,
o Existing structures and significant features on the subject property and on adjacent properties.
o Property lines, adjoining streets, and immediately adjoining properties and their ownership.
o The layout of an internal vehicular and pedestrian circulation system, including location and dimensions of existing and proposed
improvements on public rights-of-way such as roads, sidewalks, and curbs,
o Comer grades and existing contours of topography at five-foot contour intervals,
o Existing and proposed grades and volume and disposition of excavated material, if applicable
o Natural drainage direction and storm drainage facilities and improvements.
o Locations of all existing and proposed utility connections
o Parking spaces and driveways,
o Proposed landscaping,
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SCALE IN FEET
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o 1000 2000 4000
LEGEND
Proposed water lines
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PROJECT MAP FOR
LOCAL UTILITY DISTRICT #14
MARROWSTONE ISLAND
WATER SYSTEM