The URL can be used to link to this page

Home My WebLink AboutSDP2019-00016 - 12 JARPAQ WASHINGTON STATE Joint Aquatic Resources Permit Application (DARPA) Forml,2 UMU ---------------------------------------, AGENCY USE ONLY M Us :my ewlm ' Date received: ' of Eginserr i s9atauOtt i r r ; Agency reference #: ; r t ' USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SAACFSArm LOW. t ' F 1 t ------------------------------- v EFTEr SON 6.eOiJN d Y DC® Part 1—Project Identification 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) [help v f-— �.ee 7v�r t (d_, 7, ;? 7i 7 r d Lee- �a r� $ 93 /wc`,�VIA Part 2—Applicant The person and/or organization responsible for the project. heI 2a. Name (Last, First, Middle) - Van Vey, mav"lawne, 2b. Organization (If applicable) 1� 1A 2c. Mailing Address (Street or PO Box) 500 32B-tk 66te " 2d. City, State, Zip F6,raL WckWit q j a z3 2e. Phone (1) 2f. Phone (2) 2g. Fax 2h- E-mail 'Additional forms may be required for the following permits: • If your project may qualify for Department of the Army authorization through a Regional General Permit (RGP), contact the U.S. Army Corps of Engineers for application information (208) 764-3495. • Not all cities and counties accept the JARPA for their local Shoreline permits. 0 you need a Shoreline permit, contact the appropriate city or county government to make sure they accept the DARPA. ZTo access an online JARPA form with [help] screens, go to {iitla:llwww.epern}ittin .wa. avlsitelttlias resourcecenlerl'a a -jarpa fol 1998411a a #olTn as x. For other help, contact the Govemor's Office for Regulatory Innovation and Assistance at (600) 917-OD43 or IieloCrD.oda.Wa.goy. GRIA-16-011 Page 1 of 14 Part 3—Authorized Agent or Contact Person authorized to represent the applicant about the project. (Note: Authorized agent(s) must sign 11 b of this application.) hel 3a. Name (Last, First, Middle) FaL�, K4 R5 �j _ - - -- - 3b. Organization (If applicable) Net SomgA 5 o rrej i li e �by)Tf t[.`�j o n 3c. Mailing Address (Street or Po Box) 3d. City, State, Zip U,tnton -WA 1813�� - --- 3e. Phone (1) 3f. Phone (z) 3g. Fax 3h. E-mail ,3ba l 14 - `Z Ltl/ �. �/l ��3 0&b • 579 •;;Z L)_W*T�cx.�.nd short' f_ � vrx�.i I nc I u V CM Part 4--Property Owner(s) Contact information for people or organizations owning the property(ies) where the project will occur. Consider both uipland and a uatiic ownership because the upland owners may not own the adjacent aquatic land. tel 0 Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights -of -way or easements. (Skip to Part 5.) XThere are multiple upland property owners. Complete the section below and fill out JARPA Attachment A for each additional property owner. ❑ Your project is on Department of Natural Resources (DNR)-managed aquatic lands. If you don't know, contact the DNR at (360) 902-1100 to determine aquatic land ownership. If yes, complete JARPA Attachment E to apply for the Aquatic Use Authorization. 4a. Name (Last, First, Middle) 4b. Organization (If applicable) 4c. Mailing Address (Street or PO Box) 3gV7— ` `44 M& A 4d. City, State, Zip 4e. Phone (1) �-6A-39, 91 105— 5` 0 4f. Phone (2) 4g. Fax 14h. E-mail Uee-1q37 (a _c xyr-e5t, n ORIA-16-011 Page 2 of 14 Part 5—Project Location(S) Identifying information about the property or properties where the project will occur, hel ❑ There are multiple project locations (e.g. linear projects). Complete the section below and use .JAItiPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (check all that apply.)[helpl �if Private ❑ Federal ❑ Publicly owned (state, county, city, special districts like schools, ports, etc.) ❑ Tribal ❑ Department of Natural Resources (DNR) — managed aquatic lands (Complete JARPA Attachment E) 5b. Street Address (Cannot be a PO Box. If there is no address, provide other location information in 5p.)[L@jpJ 5c. City, State, Zip (If the project is not in a city or town, provide the name of the nearest city or town.)[LpJpJ 'PO r IoWvl c( 5d. County Lb_@M 2 fyr5ori 5e. Provide the section, township, and range for the project location. Lel �9ee fatIOW at(eW- WWAf '/4 Section Section Township Range S 25 30 �� 5f. Provide the latitude and longitude of the project location. el ■ Example: 47.03922 N lat. /-122.89142 W long. (Use decimal degrees - NAD 83) `i 8.0 7-f7 -]� l,at; (0 1 W Low 5g. List the tax parcel number(s) for the project location, hel • The local county assessor's office can provide this information. - _-- q. 22 dol1T And CT322 5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) two Name Mailing Address Tax Parcel # (if known) Ali c L __... 3-.7.........-..`..............._.m11..�.._ 5 qs 105 —5-4 b _ �2 6 sy '7'-� -�aao7-20 ChT15 _._... - -b_1.. � .-.......Gs . 3."_� P�.. . W.-................... a �2 13 22 6 0 I Co ORIA-16-011 Page 3 of 14 51. List all wetlands on or adjacent to the project location. hel _ 9 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. h 1 D i t wveir" L3a 5k. Is any part of the project area within a 100-year floodplain? [he! !: ' Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. 1,eii Ilc ��a�-;orn �s cGft 1av%jn CLv)C► weds. �V�Q�+r t� 'IS fiACC+i��e_rle_ I AV (.Vlo t aw are on -the- Wc�� &f 1901 � - is 1)0 I)VA ov, W,�;te'r sck- 4 &, l kf0A. 5m. Describe how the property is currently used. hel Tk 16 k4 bav" ivt WA &4v-, -�,Mt't 51ft [ato �Gcuvt'`c�Y vacu.��orn �Ira�r�' — ��2� a few tN��k�n�s ,ea.�ln Vhav�-t'h 5n. Describe how the adjacent properties are currently used. he! S6tvyl& G1.5 above-aV) 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. Lies 30' be c,1� on wat-4�Mide vF �Yt��er �� usc�9 fvr iN� evz T- 15 V101ht Cvo -fit. OoMj-�Ic) I rvcnt i� 1s V � 51 �"5. S '� �. Tic r� �s a- ao' vJ��c cl�,�O��l owl - v� Sra({ D C?a610 � oZ5' Sf - hzt i5 AC LO' X Io' b�e� 5p. Provide driving directions from the closest highway to the project location, and attach a map. neg Kga Al VIJ 1%o f k -rh. rq C>n) Yn aukm . CVA-f rriurr� Ern -}-urvL t eh- ad-D q Go v vis,,k5ad. �a I, 3 Cue- W fo 5, bt5c1ova'`� �frD , �v -Nf -*apmtr. �T.dm [tf�- WiD cCIpe, Cl-W k�, a -7 filln 1r2 Mi - t 136rw� PJ i5 on �-h, yt ORIA-16-011 Page 4 of 14 Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. hel both �. N-6 c- a e- �K Iva- rd >w 5-j� rvY, vs� To irn 5tz ered �n/i LI i� a rir�Sl� twit 6b. Describe the purpose of the project and why you want or need to perform it. hel - - &f ` hi- ea,5toM of thL b " I kktw 6a 1 �Veacw 15 CL g- of M . �C pa fff CXre heyeded -b P MUe-n-r 5A-wafv 4 ,Ar1-f+woDd -Rom L44-�,r, -�ke prz)pe,&y uthdirRat'l t� c- f o wwdAftm pf -rhe, izs ? d evcce, . t4w strw"m otoas ► - � we'&V►4m* to nor urge- in Sr m 6c. Indicate the project category. (Check all that apply) help ❑ Commercial I < Residential ❑ Institutional ❑ Transportation Recreational Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (Check all that apply) [help] ❑ Aquaculture ❑ Culvert ❑ Float ❑ Bank Stabilization ❑ Dam / Weir ❑ Floating Home ❑ Boat House ❑ Dike / Levee / Jetty ❑ Geotechnical Survey ❑ Boat Launch ❑ Ditch ❑ Land Clearing ❑ Boat Lift ❑ Dock / Pier ❑ Marina / Moorage ❑ Bridge ❑ Dredging ❑ Mining Bulkhead ❑ Fence ❑ Outfall Structure ❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Channel Modification ❑ Fishway ❑ Raft ❑ Other: ❑ Retaining Wall (upland) ❑ Road ❑ Scientific Measurement Device ❑ Stairs ❑ Stormwater facility ❑ Swimming Pool ❑ Utility Line ORIA-16-011 Page 5 of 14 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. tha�j v# Identify where each element will occur in relation to the nearest waterbody. v* Indicate which activities are within the 100-year floodplain. Rt�MR o F 5'R�1;.m f r ac a 1�U Ut��.A 0 � l tr e~ O I av" V t-A- g _ tM A}-�X i z7r' ALL UW kw, is 160,-YF^R f-WG17 PLAIN - W1 I L 667 T146 DtA-MAC-fel] �'14LKi116ckb WILL Be +WM4ED VIA ;xcA,,jA-voP.. pi---af N5 J � � l� a GSTR14144 W. Tim 8�4� ��D��k��$E fP7Yt��tbN �1� Ck-�ramL DA��RD7. V)-A611N61 ` P rAc IN PP"—,e D�E?T� ER $ILL bc �I D �5l �T �Ct NG wr i $E � � h�f! LJ ►q R v � , SW TuA010 6-06LO I~ERei) PeAw l . 6f. What are the anticipated start and end dates for project construction? (Month/Year) hel is If the project will be constructed in phases or stages, use AARPA Attaciiment I� to list the start and end dates of each phase or stage. Start Date: r- �k I �Z'I q End Date: 69. Fair market value of the project, including materials, labor, I- $ 140,5x plus -fax 6h. Will any portion of the project receive federal funding? If yes, list each agency providing funds. ❑ Yes No ❑ Don't know ❑ See JARPA Attachment D rentals, etc. hel i o�ai �ovvi�v)�Han �Nhc 13 Q d y& Part 7—Wetlands: Impacts and Mitigation ❑ Check here if there are wetlands or wetland buffers on or adjacent to the project area. (If there are none, skip to Part 8.) hel 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands.[heipi Not applicable 7b. Will the project impact wetlands? fig =�sj ❑ Yes Vl No ❑ Don't know 7c. Will the project impact wetland buffers? he, ❑ Yes V No ❑ Don't know ORIA-16-011 Page 6 of 14 7d. Has a wetland delineation report been prepared? Lelp • If Yes, submit the report, including data sheets, with the JARPA package. ❑ Yes ❑ N o 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? Lgid If Yes, submit the wetland rating forms and figures with the JARPA package. ❑ Yes ❑ No ❑ Don't know wJA 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? il,el • If Yes, submit the plan with the JARPA package and answer 7g. e If No, or Not applicable, explain below why a mitigation plan should not be required. ❑ Yes ❑ No ❑ Don't know 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. hei IMPACT 7h. Use the table below to list the type and rating of each wetland impacted, the extent and duration of the impact, and the type and amount of mitigation proposed. Or if you are submitting a mitigation plan with a similar table, you can state (below) where we can find this information in the plan. hel Activity (fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact' mitigation mitigation area flood, etc.) rating ft. or type4 (sq. ft. or cate o 2 Acres) acres ` If no official name for tfle wetland exists, create a unique name (such as "Wetland 1 "). The name should be consistent with other project documents, such as a wetland delineation report. 2 Ecology wetland category based on current Western Washington or Eastern Washington Wetland Rating System. Provide the wetland rating forms with the JARPA package. 3 Indicate the days, months or years the wetland will be measurably impacted by the activity. Enter "permanent" if applicable. "Creation C , Re-estab lishmendRehabiKali on JBI, Enhancement E , Preservation P , Mitigation Sankfin-lieu fee B Page number(s) for similar information in the mitigation plan, if available: ORIA-16-011 Page 7 of 14 711. For all filling activities identified in 7h, describe the source and nature of the fill material, the amount in cubic yards that will be used, and how and where it will be placed into the wetland. eI ti( FtLL MAfC- JkL IN V-6 NUT. 7j. For all excavating activities identified in 7h, describe the excavation method, type and amount of material in cubic yards you will remove, and where the material will be disposed. het p,LL CyCAjA-,CD rA ATERIAL- WILL R£ }�C-TtkRPY--1-S -CD i75 =G16MAL, -5;,PM. Part 8—Waterbodies (other than wetlands): Impacts and Mitigation In Part 8, "waterbodies" refers to non -wetland waterbodies. (See Part 7 for information related to wetlands.) Lbpm Check here if there are waterbodies on or adjacent to the project area. (If there are none, skip to Part 9.) 8a. Describe how the project is designed to avoid and minimize adverse impacts to the aquatic environment. 11 heI X Not applicable W L LL 0"Uk FKM l fow-�WAlkb e'OMS Vt4C 1 aN 5J-'s 0 FIAT NV 814WM• $.5 AIR Of:- 81 LKH60 S1DC-• THE (RPAP6 OF Ttw 5aL t�*M (aid TD OCC-L-4 8b. Will your project impact a waterbody or the area around a waterbody? [i-io.i l ❑ Yes �6 No ORIA-16-011 Page 8 of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non -wetland waterbodies? [heipi • If Yes, submit the plan with the JARPA package and answer Sd. • If No, or Not applicable, explain below why a mitigation plan should not be required. ❑ Yes Na ❑Don't know TAt�, Wtj( �C tTf' Va mottl VW TVIs6 ",wzd eu we ar r--e�P d" rn Ix 1l work b,avOM 00 "� -�. pa4%e- � - I wo . ae �pc+i{d �a �' dt ter oV, -tom iarldw�vr� Srd� . I Co"+VC. Ve bmps wilt b,-, im itwea 1. Thl5 will a 3 1 8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. m If you already completed 7g you do not need to restate your answer here. het Be. Summarize impact(s) to each waterbody in the table below. heI Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' Iocation2 of impact3 (cubic yards) to be linear ft.) of drive, etc.) placed in or removed waterbody from waterbody directly affected P.h1 to dll P i ilx:4- ewr . r1d US raflul (ti - 1"r. I'll od04"h 7 0`�5 `*,44— If no official name for the waterbody exists, create a unique name uch as "Stream 1") The name should be consistent with other documents provided. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent, provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 3Indicate the days, months or years the waterbody will be measurably impacted by the work. Enter " ermanent" if applicable. 8f. For all activities identified in 8e, describe the source and nature of the fill material, amount (in cubic yards) you will use, and how and where it will be placed into the waterbody. heI �-I- Re fA v wY T116 v jv r k-5 �C > 9,5 ` No V\&W �i Ll Ywtov iat r- U I (OCJ- . �n ORIA-16-011 Page 8 of 14 8g. For all excavating or dredging activities identified in 8e, describe the method for excavating or dredging, type and amount of material you will remove, and where the material will be disposed. iel Cin IVY-Rp�*� w x u. usC- AO E xc-AVXSDR -o P(no OC- Rax 2D u �s DF D�7�fi►(��T11�6 �lUJ1'C�S� �dV� /vt,��P*-:5 WN'IPIA91N y GRas6T49. lT- LAAL L' LpGfiJ� t N� v Ni✓ o j- i� tS TRLLcKs D tv gOSeP D f Part 9-Additional Information Any additional information you can provide helps the reviewer(s) understand your project. Complete as much of this section as you can. It is ok if you cannot answer a question. 9a. If you have already worked with any government agencies on this project, list them below. fl,)-in] Agency Name Contact Name Phone Most Recent Date of Contact Soa-1 3 0 37 - 5 U-"e- It, 2.b19 !Lq�w ex5a �r�•li7 p vv►en1' 9b. Are any of the wetlands or waterbodies identified in Part 7 or Part 8 of this JARPA on the Washington Department of Ecology's 3O3(d) List? hel • If Yes, list the parameter(s) below. • If you don't know, use Washington Department of Ecology s Water Duality Assessment tools at: htt s:llecoio : Na, ovMlater- 5horelinesrWater-oualitvlllyatei --improvementlAssessment-of-state-waters-303d. Yes ❑ No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? e► ■ Go to htto:llcfpLib.epa.gov/surlllocatelsnder._.cfin to help identify the HUC. �Vatd iNOT 9d. What Water Resource Inventory Area Number (WRIA #) is the project in? LeJPJ Go to htt s: acDiogy.wa.LovlWater-Slioreiii-ies/vvater-suppivmatei--availabillty!Watershed-look-up to find the WRIA #. ORIA-16-011 Page 10 of 14 9e. Will the in -water construction work comply with the State of Washington water quality standards for turbidity? Le_l ■ Go to lit! s:llecolo .wa. ovNVater-5herelines/Water- ualit IFreshwaterlSurFace-water uaiit _standard ;Crited i for the standards. ❑ Yes ❑ No Not applicable 9f. If the project.is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? hlM ■ If you don't know, contact the local planning department. • For more information, go to: 3ittos:lleco{aay.wa.4aylWater-Shore lities/Shorelire-coastal-management!Shoreline-coastal- s)lann i ng I S hor eli ne -laws -ru ie s-and - cases. ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy Other: 99. What is the Washington Department of Natural Resources Water Type? hei ■ Go to http:llwww.dnr.wa.govl#ofp.gt-practices.•water ing. for the Forest Practices Water Typing System. r_�h7oreline ❑ Fish ❑ Non -Fish Perennial ❑ Non -Fish Seasonal 9h. Will this project be designed to meet the Washington Department of Ecology's most current stormwater manual? h( of ■ If No, provide the name of the manual your project is designed to meet. Yes ❑ No Name of manual: \A M Mfb it fi 9L Does the project site have known contaminated sediment? hei m If Yes, please describe below. ❑Yes No 9j. If you know what the property was used for in the past, describe below. hel 9k. Has a cultural resource (archaeological) survey been performed on the project area? hei If Yes, attach it to your JARPA package. ❑ Yes No ORIA-16-011 Page 11 of 14 91. Name each species listed under the federal Endangered Species Act that occurs in the vicinity of the project area or might be affected by the proposed work. bgjpj Noel & 9m. Name each species or habitat on the Washington Department of Fish and Wildlife's Priority Habitats and Species List that might be affected by the proposed work. hel No tilt, Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. it Online Project Questionnaire at http://apps.oria.wa.gov/opast. s Governor's Office for Regulatory Innovation and Assistance at (800) 917-0043 or helpC)_oria.wa.gov_. o For a list of addresses to send your JARPA to, click on agency addresses for completed JARR . Oa. Compliance with the State Environmental Policy Act (SEPA). (check all that apply.) hel 49 For more information about SEPA, go to litips;llecologv.wa.govire uiations•nermi!a EPA -environmental -review. ❑ A copy of the SEPA determination or letter of exemption is included with this application. ❑ A SEPA determination is pending with is (lead agency). The expected decision date ❑ 1 am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 10b.) LtRipj This project is exempt (choose type of exemption below). Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? sbo Ir. ❑ Other: ❑ SEPA is pre-empted by federal law. I ORIA-16-011 Page 12 of 14 a 10b. Indicate the permits you are applying for. (Check all that apply.) el LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance XShoreline Exemption Type (explain): Other City/County permits: ,Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish a d W1ldlffe: Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption — Attach Exemption Form Washington Department of Natural Resources: ❑ Aquatic Use Authorization Complete DARPA Attachment E and submit a check for $25 payable to the Washington Department of Natural Resources. Do not send cash. ZS hington Department of Ecology: ection 401 Water Quality Certification FEDERAL AND TRIBAL GOVERNMENT V. United States Department of the Army (U.S. Army Corps of Engineers): Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters) n ted States Coast Guard: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non -bridge projects) United States Environmental Protection Agency: ❑ Section 401 Water Quality Certification (discharges into waters of the U.S.) on tribal lands where tribes do not have treatment as a state (TAS) Tribal Permits: (Check with the tribe to see if there are other tribal permits, e.g., Tribal Environmental Protection Act, Shoreline Permits, Hydraulic Project Permits, or other in addition to CWA Section 401 WQC) ❑ Section 401 Water Quality Certification (discharges into waters of the U.S.) where the tribe has treatment as a state (TAS). ORIA-16-011 Page 13 of 14 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. [i.,-i-j i 11 a. Applicant Signature (required) hel I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to cant' out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize the agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies entering the roperty where the project is located to inspect the project site or any work related to the project. (initial) Ala ia>1ne E. VannNvve-r Applicant Printed Name Applic nt Signature Date F"VQ ow✓>er 14- I T 11 b. Authorized Agent Signature heI I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to cant' out the proposed activities and I agree to start work only after all necessary permits have been issued. Narne Date 11 C. Property Owner Signature (if not applicant) [hel Not required if project is on existing rights -of -way or easements (provide copy of easement with JARPA). 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. 6 A 1 r Property Owner Printed Name Propert0owner Signature Dike W W- 18 18 U.S.0 §1001 provides that: Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any false, fictitious, or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more Lhan 5 years or both. if you require this document in another format, contact the Governor's Office for Regulatory Innovation and Assistance (ORIA) at (800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call (877) 833- 6341. ORIA publication number: ORIA-16-011 rev. 0912018 ORIA-16-011 Page 14 of 14 i 1L �ry WASHINGTON STATE 0 Joint Aquatic Resources Permit Application (DARPA) hem Attachment A: For additional property owner(s) [heir), Use this attachment only if you have more than one property owner. Complete one attachment for each additional property owner impacted by the project. � --------------Y -------- ---- { � I Date received: Agency reference #: Tax Parcel 4(s): � I I I , , I , I , I 1 , t•o ar_ranse�trirn sv nrt�t.rcAtv�- ,a , , T Project Name:''rr MD1V�R- t% BIALK►+�Ai7 , Location Name (if applicable): I I I ! '-------------------------------------' 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 answers in whites aces below. 1. Name (Last, First, Middle) and Organization (if applicable) -- Le,e M • 2. Mailing Address (Street or PO Box) - 3967 - 41"JI ve . NE 3. City, State, Zip Seaf le 4. Phone (1) 5. Phone (2) 6. Fax 7. E-mail 2.o6.5;Z4_51at tYlA IVIA b)te q31 nmst. llt?t Address or tax parcel number of property you own: 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. 6�L JP 'E- Printed Name Signatur If you require this document in another format, contact the Governor's office for Regulatory Innovation and Assistance (ORIA) at (800) 917-0043. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability can call (877) 833-6341. ORIA publication number: OR A-15-012 rev, 1012016 JARPA Attachment A Rev. 10/2016 Page 1 of 1