HomeMy WebLinkAboutDuckabush-Jefferson County - SHR Application - 2/8/2007 02/08/ZOU7 16:31 NAA ZUb 5?JZ !JUij Lotrg Live i n1UKh W.J
o, �vu/ iu, U(AIVI IKAUIMAN MAHER & ASSOC,
No. 4109 P.
2
�0 JEFFERSON COUNTY
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street • Port Townsend • Washington 98368
360/379-4450 • 360/3'79-4451 Fax
rN 0i www.co.jetfer'son.wa.us/commdeveiopment
Master Permit Application MLA:
Project Description (include separate sheets as necessary):
Hood Canal Steelhead Supplementation Project Juvenile Monitoring
Tax Parcel Property
Number 502074022 Size:
(acreslsJarefeet)
Site Address and/or Directions to Property; 1585 Duckabush Rd. Brinnon, WA
Follow Coyote Rd. down to the river via a private,gated drive
Property Owner(s)of Record: atty Ison, secretsty Duckabush Communit .
Telephone 206-367-0423 Fax:
email,.
Mailing Address: 14034 36th St. NE, Seattle, WA, 98125.
Applicant/Agent(if different from owner): Long Live the Kings
Telephone:M-382,9555 Fax:
email:
Mailing Address: 1326 51h Ave,Ste,450,Seattle,WA, 98101.
What kind of Permit?(Check each box that applies)
❑Building ❑Variance(Minor, Major or Reasonable Economic Use)
O Demolition Permit O Conditional Use (C(a), C(d),or Cj
❑ Single Family 0 Discretionary"D"or Unnamed Use Classification
O Garage Attached/Detached ❑ Special Use(Essential Public Facilities)
Cl Manufactured Home O Boundary Line Adjustment
❑ Modular ❑Short Plat'-
Q Commercial" ❑ Binding Site Plan"^
0 Change of Use ❑ Long Plat°"
❑ Address ❑Road Approach- El Planned Rural Residential Development(PRRD)/Amendments"
O PropaneO Plat Vacation/Alteration '•
❑Allowed"Yes"Use Consistency Analysis O Shoreline Master Program Exemption/Permit Revisions"'
❑ Stormwater Management 2)Shoreline Management Substantial Development`*
0 Site Plan Approval'Advance Determination (SPAAD) ` ❑Shoreline Management Variance
❑Temporary Use O Comprehensive Plan/UDC/Land Use District Map Amendment
❑Wreless Telecommunication` O Jefferson County Shoreline Master Program Amendment
O Forest Practices Act/Release of Six-Year Moratorium O Tree Vegetaion Request
'May require a Pre_Appl/caUon Conference ""Requires a Pre-Application Conference
Please identify any other local,state or federal permits required for this proposal, if known;
DESIGNATION OF AGENT
hereby designate to act as my agent in matters relating to this application for permit(s).
OWNER SIGNATURE Date: I
y signing this application form,the owner/agent attests that the mtormation provided herein,and In 8ny&ttachments,is rue and correct fo the best of
her or d'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 Ming null and void.
I further agree to save,indemnify and hold harmless Jefferson County against ail liabilities,judgmenl6,Court Costs, reasonable attorney's fees and
expenses which may in any way accrue against Jefferson County as a resuq of or in consequence of the granting of this permit.
1 further agree t sand light of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application
review end raqulrad lat inspections, ess and right of entry wilt be assumed unions the applicant informs the County in writing at the
time of the plicatic th a or an
Se�Y� c.✓
Signature, B 6 Date:
The action or ac ions Applicant will undertake as a result of the ibsuance of this permit may negative impact upon one or more threaten7orendangered spectres and coud lead to a potential'take"of an endangered species as those terms are defined in the federal law known'Endangered Spuiss Acr'or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken becpermit has been issued will not violate the ESA. Any indlvidual,group or agency can file a iawsui on behalf of an endangered species r
action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds indlvidual
and non-tra ferable responsibility for hexing to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below.
Signature: ` kr-;-—e, x' M r', tf (yc c, r3 t r- L L4_, c r1'_-c Date,_ a U
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C Dncurnwrg and Scc6nss\cara1\Local Scrtingr\Temporary rntamct f'0&*\0LI(S6\M2Lsu:r Permit Applicmio) 12-19-2(W.doc