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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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OEPT. OF CU!v1l'l,lJiii i i
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MLA:
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Tax Parcel
Number:
See attached
ProP7rty 2 0 0 4
SIZe:. (acres/square feet)
George Road, Port Townsend, WA 9836
Site Address and/or Diredions to Property: 7 4 Ole ape
Property Owner(s) of Record: We For e, L L C
Telephone: 480 - 5 96- 9012 Fax: 480 - 5 96 - 0153
Mailing Address: 7 3 7 7 E. D 0 U b 1 e t r e e Ran c h R d " # 1 t1 0 ,
Applicant/Agent (if different from owner): J err V S m i t h
Telephone: 360 - 531... 0462 Fax: 360.,. 3 4 3... 0 285
Mailing Address: PO Box 8 5 5. 23 2 Fer n Way. Chi m a cum ,
email: m i k e @ a s m u n d son g 0 1 f , com
Scottsaale, A2 85258
email: jerrphyl@aolypen.cm
WA 98325
What kind of Penn it? (Check each box that applies)
o BuDding
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
'tJ~ormwater Management
o Site Plan Approval Advance Determination (SPAAD) *
o Temporary Use
o Wireless Telecommunication *
~~orest Practices ActlRelease of Six-Year Moratorium (? )
* May require a Pre -Application Conference
o Variance (Minor, Major or Reasonable Economic Use)
o Conditional Use [C(a), C(d), or C] **
o Discretionary "0" or Unnamed Use Classification
o Special Use (Essential Public Facilities) **
o Boundary Line Adjustment
o Short Plat **
o Binding Site Plan **
~XLong Plat **
)(])(Planned Rural Residential Development (PRRD)/Amendments **
o Plat Vacation/Alteration **
o Shoreline Master Program ExemptionlPermit Revisions **
o Shoreline Management Substantial Development **
o Shoreline Management Variance
o Comprehensive Plan/UDCIland Use District Map Amendment
o Jefferson County Shoreline Master Program Amendment
**Requires a Pre-Application Confenmce
Please identify any other local, state or federal pennits required for this proposal, if known:
Refer to SEPA checklist
DESIGNATION OF AGENT
I hereby deSignate~ S m i t h to ad as my agent in matters relating to this application for permit(s),
OWNERSIGNATU~' t?'~~~, . Date: ~
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
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 provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
review a~. an required later inspections, Access and right of entry to this property shall be requested and shal.1 0 ccur only during regular business
hours. .' -.. / .. .., .. / A ~ . - / - ~~ _
Signature: ~ ~. Date: -4fJ
,
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) even if you are in compliance with the Jefferson County development code. The Applicant acknowledges that he, she or it holds individual
and non-1I:aAf1IJ1bl~ r,sponsi~i1ity f~..hering to and ~plying with the ESA. The Applicant has read this dis~~yan~igns af O~t below:...
Signature:~ ~, Date: $j'SJE-"s # :J ITE.
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