HomeMy WebLinkAboutAttachment_D_Prop_Owner_SignaturesIIAGENCYUSEONLY
TO BE COMPLETED BY APPLICANT [helDl
Project Name:
Location Name (if applicable):
Use this attachment onlv if you have more than one property owner.
Complete one attachment for each additional property owner
impacted by the project.
Signatures of property owners are not needed for repair or maintenance activities on existing rights-of-way or
easements.
Use black or blue ink to enter in white below
WASHINGTON STATE
Joint Aquatic Resources Permit
Appl ication (JARPA) rn":ur
Attachment A:
For additional property owner(s) rnsrr:
US Army Corp6
ol Engineers 'Ser*e tli$d Date received:
Agency reference #:
Tax Parcel #(s):
or ANSWCTS
1. Name (Last, First, Middle) and Organization (if applicable)
United States of America (Olympic NF)
2. Mailing Address (Street or PO Box)
437 Tillicum Lane
3. City, State, Zip
Forks, WA 98331
4. Phone (r) I 5. Phone rzl I 6. fax 7. E-mail
360-374-6522
Address or tax parcel number of property you own:
711-283-003
Signature of Property Owner
I consent to the permitting agencies entering the property where the project is located to inspect the project
site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the
landowner.
Pdnted Name Signature
JARPA Attachment A Rev.10/2016 Page 1 of 'l
lf you require this document in another format, contact the Governor's Office for Regulatory lnnovation and Assistance (ORIA) at
(800) 917-0043. People with hearing loss can call711 for Washington Relay Service. People with a speech disability can call
833-6341. OR|A number: ORIA-1 6-01 2 rev. 1A12016
I
I
I
I
t
I
I
I
L