HomeMy WebLinkAboutDuckabush-Jefferson County - SHR Application - 2/8/2007 02/08/2007 1b: 31 11AA ZUb J6Z !jUlo 10119 Ltve cue niueh wjvvl
o. /uvl lu: U/HM INAUIMAN MAHER & ASSOC,
i cad No, 4109 P. 2
JEFFERSON COUNTY
y� DEPARTMENT OF COMMUNITY DEVELOPMENT
g `4 621 Sheridan Street • Port Townsend Washington 98368
3601379-4450 • 360/379-4451 Fax
NO-` Q www.co.jefferson.wa.us/commdevelopment
Master Permit Application pp ton MLA:
Project Description(include separate sheets as necessary):
Hood Canal Steelhead Supplementation Project: Juvenile Monitoring
Tax Parcel Property
Number 502074022 Size: (acres/square feet)
Site Address and/or Directions to Property: 1565 Duckabush Rd. Brinnon, WA
Follow Co Vote Rd. down to the river via a private, gated drive
Property Owners)of Record: _ atty (son, secretary Duckabush Community.
Telephone: 206-367-Od23 Fax. email
Mailing Address: 14034 36th St. NE, Seattle, WA, 98125 _
ApplicaM/Agent(if different from owner): Long Live the Kings
! Telephone:M-382.9555 --
Fax; email:
Mailing Address: tags 51h Ave,Ste.450,Seattle, WA, 98101.
What kind of Permit? (Check each box that applies)
OBuilding ❑Variance(Minor, Major or Reasonable Economic Use)
O Demolition Permit O Conditional Use (C(a), G(d),or Cj"
❑ Single Family 0 Discretionary"El"or Unnamed Use Classification
O Garage Attached/Detached O Special Use(Essential Public Facilities)"•
11 Manufactured Home O Boundary Line Adjustment
0 Modular O Short Plat"
❑ Commercial" ❑Binding Site Plan
❑ Change of Use ❑ Long Plat"
❑ Address El Road Approach ❑Planned Rural Residential Development(PRRD)/Amendments"
O Propane O Plat Vacation/Alteration '"
❑Allowed"Yes'Use Consistency Analysis O Shoreline Master Program Uemption/Permit Revisions
O Stormwater Management E Shoreline Management Substantial Development
❑Site Plan Approval Advance Determination (SPAAD) ` ❑Shoreline Management Variance
O Temporary Use O Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wrefess Telecommunication` O Jefferson County Shoreline Master Program Amendment
❑ Forest Practices Act/Release of Six-Year Moratorium O Tree Vegetaion Request
'May require a Pro—Application Conference "'Requires a Pro-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known;
DESIGNATION OF AGENT
I hereby designate to act as my agent in matters relating to this application for permit(s),
OWNER SIGNATURE Date.
y 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/ag®nt with respect to this appficalion 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 t I s and right of entry to Jefferson County and its employees, representatives cr agents for the sole purpose of application
review and requlrad lat inspections, Staff access and right of entry wilt be assumed unless the applicant informs the County in writing at the
time o(tl+e plicalio th a or s an(s n ce
Signature, \ (�
Date:
The action or ac ions Applicant will undertake as a result of the issuance of this permit may negative 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 SpaaieS Acr•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 fife 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-trapfe�ra�blo rosponsibility for herring to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature ' cT Yv`'d ►y-6k ��' C_aA,1 )xJ (yc c. rJ i r- I " (�u.v-c > --� Date
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