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Section 1
JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street. Port T~se,rd; .~tllliqfOrf~
360/379-4450' 360/379-4t!1 a>4 !J) '''', u u
www.cO.jefferSOn.wa.us/cor\ feropmem
Master Permit Application I: AUG - 5
Project Description (include separate sheets as necessi:lry):
Tax Parcel
Number:' 002231001 002242003
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Size: 92 acres
(acres/square feet)
Site Address and/or Directions to Property: 495-1220 Beckett Point Road & 10-150 Viewpoint Road
Properly Owner(s) of Record: Beckett Point Fishermen's Club c/o Patti Sahlinger
Telephone: 360/385-0428 Fax:
Mai' dress: 890 Beckett Point Road, Port Townsend, WA 98368
pplican ~gent (if different from owner): Jefferson County P,U.D, #1
e ephone: 360/385-5800 Fax: 360/385-5945
Mailing Address: 230 Chimacum Road, P,O, Box 929 Port Hadlock, WA 98339
email:
Attn: James Parker (Applicant)
email: jparker@jeffpud.org
.
What kind of Permit? (Check each box that applies)
o Building
o Demolition Pennit
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
IZl Stonnwater 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)
IZI 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 ..
IZl 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:
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, 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
m~y 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 provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
review and any require la r inspections, Access and right of entry to this property shall be requested and shall occur only during regular business
hours, fJ/1f / rC.
Signatu Date: l5 II ()J
DESIGNATION OF AGENT
to act as my agent in matters relating to this application for permit(s),
.. Date: 2 /5/o.s-
, /
I hereby designate Jean Carr, Parametrix, Inc,
1
OWNER SIGNATURE
AI
The ac actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more th reatened 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 be.e. issued will n~,,',y;ola.te t. SA, Any individual, group or agency can file a lawsuit on behalf of an en..dangered species re,g, arding your
action(s) eve~ if yare in co ance ith the Jefferson County development code, The Applicant acknowledges that he, she or it holds individual
and non-trans~r .. I , r;sponsi 'Ii for \ dh ring to and complying with the ESA, The Applicant has read this di~ai~. r and,Sign~/i1p-~ fja}e&it below,
Signature: i~' /',' ' ..~ Date: ,) i/fe-UJJ/:fyt. )t;V, }
i J Lor; ~''-' A
C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-S.04,dOC__-"__,,_L____"
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OWNER BUILDER STATEMENT
. The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein, that they are not licensed contractors and that
, they will be assuming the responsibility of the General Contractor for the proposed project.
Signature: N/ A Date:
GENERAL CONTRACTOR OR MANUFACTURED HOME IN
N/A
MAILING ADDRESS:
CONTRACTOR'S liCENSE
NUMBER:
ARCHITECT/ENGINEER:
MAILING ADDRESS:
FAX: (
If this is a Commercial Proiect you must answer the followinQ:
Number of Parking Spaces: Current: NfA Proposed: N/A Number of ADA Parking Spaces: NfA
Number of occupants (includes owners, tenants, employees, etc) Current 90 residences Proposed
IBC Occupancy: N/A IBC Type of construction: NfA Will you have Food Service? Yes / No
If this is a Propane Tank and/or Appliance Installation permit. mark all items below that applv:
i Underground Tank i Above ground Tank Size of Propane Tank:
i Heat Stove i Cook Stove i Woodstove i Fireplace Insert i Hot Water Tank i Pellet Stove i Other
Is this appliance beinQ installed in a Manufactured / Mobile Home? Yes / No
When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings, all properly
lines, tank location and size, distances from the propane tank to all properly lines, buildings and septic system components,
includin the reserve area.
S uare Foota e
Current Pro osed
Project Type: N/A
o New
o Addition
o Alteration/Remodel
o Repair
o Demolition
Type of Heat:
.
Main Floor
N/A
2 Floor
N/A
3r Floor
N/A
Mezzanine:
N/A
Heated Basement
N/A
Unheated Basement
N/A
Other Unheated
N/A
Garage/Carport N/A
Decks
Other
N/A
FAX:
i.-".....,.,.__....__ ..'
Frame Type:
o Wood N/A
o Steel
o Concrete
o Masonry
o Other:
Shoreline:
Type of Sewage Disposal:
o Sewer
o Community System
o Individual System
SEP Permit #
Water Supply:
o Private well 0 Two Party
o Public
Name of System:
Bathrooms:
Existing:
Proposed:
Total:
N/A
Bank
Height:
Bedrooms:
Existing:
Proposed:
Total:
Setback:
.
N/A
ESTIMATED COST (REQUIRED)
-Fair market value of aI/labor and materials foundation to finish
C:\Documents and 5ettings\mochil\Desktop\Master Permit Application 7-8-04,doc