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June 7, 2006
Mr. Al Scalf
Department of Community Development
Jefferson County
621 Sheridan Street
Port Townsend, W A 98368
Re: Ludlow Cove Division II
Dear Mr. Scalf:
This letter accompanies an application by our clients, Trendwest Resorts, Inc., and Port
Ludlow Associates LLC, for a Shoreline Substantial Development Permit for construction of a
120-unit residential timeshare complex on 14.66 acres at Ludlow Cove. A Shoreline Substantial
Development Permit for exactly the same project was approved by the Jefferson County Hearing
Examiner in September 2005. In March 2006, however, Port Ludlow Associates LLC submitted
a request for an amendment to the Port Ludlow Development Agreement. In order to be certain
that the Shoreline Substantial Development Permit for this project is consistent with the
proposed amendment to the Development Agreement, and because the approved Shoreline
Substantial Development Permit is under appeal, we are resubmitting the application.
In accordance with Section 7 of the Land Use Application Procedures Ordinance
(Ordinance No. 04-0828-98), which governs the development ofland subject to the Port Ludlow
Development Agreement, we are requesting that this Shoreline Substantial Development Permit
application be consolidated with .the request for an amendment to the Port Ludlow Development
Agreement. The purpose of the amendment to the Development Agreement is to clarify that
timeshare uses may be constructed on the Ludlow Cove Division II property, and this Shoreline
Substantial Development Permit is for the development oftimeshare units as contemplated by
the amendment to the Development Agreement. Accordingly, the two permits are related and
should be processed simultaneously in a consolidated manner as provided in Section 7 of the
Land Use Application Procedures Ordinance.
Because this is exactly the same project for which a Mitigated Determination of Non-
Significance was issued by Jefferson County in 2005, we request that the Mitigated
Detennination of Non-Significance, the SEPA Checklist, any reports and studies, and all other
environmental documents in the possession of Jefferson County and relating to this project be
LOG iTEM
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Mr. AI Scalf
June 7, 2006
Page 2
adopted by the County pursuant to WAC 197-11-630, in satisfaction of the County's obligations
under the State Environmental Policy Act, RCW Chapter 43.21 C, relating to both the Shoreline
Substantial Development Permit and the amendment to the Port Ludlow Development
Agreement. The County should adopt and distribute notice of the adoption in accordance with
WAC 197-11-630(2). The notice of adoption should describe the proposed Shoreline Substantial
Development Permit and the amendment to the Port LUdlow Development Agreement.
We ask that the County provide expedited review of this permit application along with
the amendment to the Development Agreement. We request that the Jefferson County Board of
County Commissioners set a date for a hearing on the matter, and we request that the
Commissioners hold the open record hearing rather than referring it to the Hearing Examiner.
Our request is based on the fact that this is part of a very complex project, which has much
history associated with it. Asking a Hearing Examiner, new to Jefferson County, to review this
application and the amendment to the Development Agreement relative to all that history
imposes a substantial burden on the Hearing Examiner.
If you have any questions regarding the foregoing, please contact either Marco de Sa e
Silva at (206) 628-7766 or Donald Marcy at (206) 254-4465. Thank you very much for your
assistance in this matter.
~ A ~~Wt
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Caimcross & Hempelmann, P.S.
524 Second Ave., Suite 500
Seattle, Washington 98104
Marco de Sa e Silva .
Davis Wright Tremaine LLP
2600 Century Square
1501 Fourth Avenue
Seattle, Washington 98101
DEMlkgb
Enclosures
cc: Ms. Barbara Nightingale
Mr. David Alvarez
Mr. Randy Verrue
Ms. Diana Smeland
Mr. Wayne Helm
Mr. Lyn Keenan
{004280S4.DOC;2)
Circulated by:
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JOINT AQUATIC RESOURCES PERMIT APPLICATION FORM (JARPA)
(for use in Washington State)
PLEASE TYPE OR PRINT IN BLACK INK
o Application for a Fish Habitat Enhancement Project per requirements of RCW 77.55.290. You must submit a copy
of this completed JARPA application form and the (Fish Habitat Enhancement JARPA Addition) to your local
Government Planning Department and Washington Department of Fish & Wildlife Area Habitat Biologist on the same day.
NOTE: LOCAL GOVERNMENTS - You must submit any comments on these projects to WDFW within 15 working days.
Based on the instructions provided, I am sending copies of this application to the following: (check all that apply)
o Local Government for shoreline: IElSubstantial Development 0 Conditional Use 0 Variance 0 Exemption 0 Revision
o Floodplain Management 0 Critical Areas Ordinance
o Washington Department of Fish and Wildlife for HPA (Submit 3 copies to WDFW Region)
o Washington Department of Ecology for 401 Water Quality Certification (to Regional Office-Federal Permit Unit)
o Washington Department of Natural Resources for Aquatic Resources Use Authorization Notification
o Corps of Engineers for: 0 Section 404 0 Section 10 permit
o Coast Guard for General Bridge Act Permit
o For Department of Transportation projects only: This project will be designed to meet conditions of the most current Ecology/Department of
Transportation Water Quality Implementing Agreement
SECTION A . Use for all permits covered by this application. Be sure to ALSO complete Section C (Signature Block) for all permit applications.
1. APPLICANT
Port Ludlow Associates, LLC/Trendwest Resorts
Attention: Mark DorseylWayne Helm
MAILING AODRESS
70 Breaker Lane, Port LudlowWA 98365/9805 Willows Road NE, Redmond WA 98052
WORK PHONE E.MAIL ADDRESS
360.437.2101/425.498.2688
M Dorsev@portludlowassociates.com
wayne. helm@cendant-trg.com
If an agent is acting for the applicant during the permit process, complete #2. Be sure agent signs Section C (Signature Block) for all permit
applications
HOME PHONE
FAX #
360.437.2522
425.498.3062
2. AUTHORIZEO AGENT
Nicole Faghin, Reid Middleton Inc.
MAILING ADDRESS
728 134th Street SE, Suite 200 Everett, WA 98204
WORK PHONE
425.741.3800
E.MAIL ADORESS
nfaghin@reidmidd.com
HOME PHONE
FAX #
425.741.3900
3. RELATIONSHIP OF APPLICANT TO PROPERTY: 00 OWNER 0 PURCHASER 0 LESSEE 0 OTHER:
4. NAME, ADDRESS. AND PHONE NUMBER OF PROPERTY OWNER(S). IF OTHER THAN APPLICANT:
(See above)
5. LOCATION (STREET ADDRESS, INCLUDING CITY, COUNTY AND ZIP CODE, WHERE PROPOSED ACTLVITY EXISTS OR WILL OCCUR)
Paradise Bay Road at Breaker Lane (extended)
Port Ludlow, WA 98365
LOCAL GOVERNMENT WITH JURISDICTION (CITY OR COUNTY) Jefferson County
JARPA, Revised 7/02 Contact the State of Washington Office of Permit Assistance for latest version, 360/407-7037 or 800/917-0043
1
WATERBODY YOU ARE WORKING IN TRIBUTARY OF
Port Ludlow Bay pugat Sound
IS THIS WATERBODY ON THE 303(d) LIST? YES CJ NO lEI
IF YES, WHAT PARAMETER(S)?
hUn:llwww.ecv.wa.l!ov/programs/wa/links/imDaired wITs.hlml WEBSITE FOR 303d
LIST
WRIA#
WRIA #17
Yo SECTION SECTION TOWNSHIP RANGE
17 28 N 1 E.
WM
GOVERNMENT LOT
SHORELINE DESIGNATION
Urban
LATITUDE & LONGITUDE:
ZONING DESIGNATION
Port Ludlow Master Planned Resort
Lat.
Long.
TAX PARCel NO:
968800102
DNR STREAM TYPE. IF KNOWN
Type 5
. DESCRIBE THE CURRENT USE OF TliE PROPERTY, AND STRUCTURES EXISTING ON THE PROPERTY. HAVE YOU COMPLETED ANY PORTION OF THE PROPOSED ACTIVITY ON THIS
PROPERTY? YES IRI NO FOR ANY PORTION OF THE PROPOSED ACTIVITY ALREADY COMPLETED ON THIS PROPERTY, INDICATE MONTH AND YEAR OF COMPLETION.
The site is currently undeveloped; the site was a former commercial log dump facility owned and operated by the Pope &
Talbot Company for over 100 years.
Ludlow Cove Division 1 (17 single-family dwellings) borders the project site to the north and east. Paradise Bay Road
borders the project site on the west.
IS THE PROPERTY AGRICULTURAL LAND? 0 YES IRINO
ARE YOU A USDA PROGRAM PARTICIPANT? CJ YES IRINO
7a. DESCRIBE THE PROPOSED WORK THAT NEEDS AQUATIC PERMITS: COMPLETE PLANS AND SPECIFICATIONS SHOULD BE PROVIDED FOR All. WORKWATERWARD OF THE ORDINARY
HIGH WATER MARK OR LINE, INCLUDING TYPES OF EQUIPMENT TO BE USED. IF APPLYING FOR A SHORELINE PERMIT, DESCRIBE AlJ. WORK WITHIN AND BEYOND 200 FEET OF THE
ORDINARY HIGH WATER MARK. IF YOU HAVE PROVIDED ATTACHED MATERIALS TO DESCRIBE YOUR PROJECT, YOU STIll. MUST SUMMARIZE THE PROPOSED WORK HERE. ATTACH
A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED.
Ludlow Cove Division 2 will encompasses six residential timeshare buildings, one reception/recreation building, a private
road system, recreational amenities including a private swimming pool, outdoor barbecues, spas, and public and private
trails. The proposed project will be served by public water and sanitary sewer systems, and a storm drainage system, An
existing wetland and Type 5 stream, together with their associated buffers, will be located in a native growth protection
easement. the boundaries of which were established as part of the Ludlow Cove Division 1 platting process. No work is
proposed below the Ordinary High Water (OHW) mark of Port Ludlow Bay.
Vehicular access to the new development will be provided via a new private road off Paradise Bay Road.
Residential development is a "primary use" within the Urban shoreline environment.
A site plan, storm drainage plan, water and sewer plan, landscaping plan and building elevations are attached to this
application.
PREPARATION OF DRAWINGS: SEE SAMPLE DRAWINGS AND GUIDANCE FOR COMPLETING THE DRAWINGS. ONE SET OF ORIGINAL OR GOOD QUALIrY REPRODUCIBLE DRAWINGS
~ BE A TTACHED. NOTE: APPLICANTS ARE ENCOURAGED TO SU8MIT PHOTOGRAPHS OF THE PROJECT SITE, BUT THESE 00 NOT SUBSTITUTE FOR DRAWINGS. THE CORPS OF
ENGINEERS AND COAST GUARD REQUIRE DRAWINGS ON ,.1/2 X 11 INCH SHEETS. ~RGER DRAWINGS MAYBE REQUIRED BY OTHER AGENCIES.
7b. DESCRIBE THE PURPOSE OF THE PROPOSED WORK AND WHY YOU WANT OR NEED TO PERFORM IT AT THE SITE. PLEASE EXPLAIN ANY SPECIFIC NEEDS THAT HAVE INFLUENCED
THE DESIGN.
The proposed project is construction of a 120-unit residential development on a 14.66-acre site known as Ludlow Cove
Division 2.
Ludlow Cove Division 2 will encompasses six residential buildings, one reception/recreation building, a private road system,
recreational amenities including a private swimming pool, outdoor barbecues, spas, and public and private trails. The
JARPA, Revised 7/02 Contact the State of Washington Office of Permit Assistance for latest version, 360/407-7037 or 800/917-0043 2
proposed project will be served by pub ater and sanitary sewer systems, and a drainage system. An existing
etland and Type 5 stream, together with their associated buffers, will be located within a Native Growth Protection
Easement, the boundaries of which were established as part of the Ludlow Cove Division 1 platting process. It is anticipated
all work will be completed in one construction phase, however individual buildings may be completed and occupied
sequentially.
No work is proposed below the Ordinary High Water (OHW) mark of Port Ludlow Bay.
7c. DESCRIBE THE POTENTIAL IMPACTS TO CHARACTERISTIC USES OF THE WATER BODY. THESE USES MAY INCLUDE FISH AND AQUATIC LIFE, WATER QUALITY, WATER SUPPLY,
RECREATION, and AESTHETICS. IDENTIFY PROPOSED ACTIONS TO AVOID, MINIMIZE. AND MITIGATE DETRIMENTAL IMPACTS. AND PROVIDE PROPER PROTECTION OF FISH AND
AQUATIC LIFE. IDENTIFY WI-IICH GUIDANCE DOCUMENTS YOU HAVE USED. ATTACH A SEPARATE SHEET IF ADDITIONAL SPACE IS NEEDED.
The proposed project will not impact Port Ludlow Bay. No work is proposed below the Ordinary High Water (OHW) mark of
Port Ludlow Bay,
7d. FOR IN WATER CONSTRUCTION WORK. WILL YOUR PROJECT BE IN COMPLIANCE WITH THE STATE OF WASHINGTON WATER QUALITY STANDARDS FOR TURBIDITY
WAC 173.201A-ll0? [] YES 0 NO (SEE USEFUL DEFINITIONS AND INSTRUCTIONS) No in-water work is proposed.
8. WILL THE PROJECT BE CONSTRUCTED IN STAGES?
DYES [B]NO
PROPOSED STARTING DATE: Fall 2006
ESTIMATED DURATION OF ACTIVITY: 18 months
9. CHECK IF ANY TEMPORARY OR PERMANENT STRUCTURES WILL BE PLACED; N/A
o WATERWARD OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH OR TIDAL WATERS; AND/OR
OWATERWARD OF MEAN HIGHER HIGH WATER LINE IN TIDAL WATERS
10. Will FILL MATERIAL (ROCK, FILL. BULKHEAD, OR OTHER MATERIAL) BE PLACED: No
D WATERWARO OF THE ORDINARY HIGH WATER MARK OR LINE FOR FRESH WATERS?
D WATERWARO OF THE MEAN HIGHER HIGH WATER FOR TIDAL WATERS?
IF YES, VOLUME (CUBIC YARDS) IAREA (ACRES)
IF YES, VOLUME (CUBIC YARDS) AREA (ACRES)
11. WILL MATERIAL BE PLACED IN WETLANDS?
IF YES:
No
DYES [B]NO
A. IMPACTED AREA IN ACRES:
B. HAS A DELINEATION BEEN COMPLETED? IF YES, PLEASE SUBMIT WITH APPLICATION.
C. HAS A WETlAND REPORT BEEN PREPARED? IF Yes. PLEASE SUBMlTWlTH APPLICATION.
D. TYPE AND COMPOSITION OF FilL MATERIAL (E.G., SAND, ETC.):
E. MATERIAL SOURCE:
F. LIST ALL SOIL SERies (TYPE OF SOIL) LOCATED AT THE PROJECT SITE, & INDICATE IF THEY ARE ON THE COUNTY'S LIST OF HYDRIC SOILS. SOILS INFORMATiON CAN BE OBTAINED
FROM THE NATURAL RESOURCES CONSERVATION SERVICE (NRCS):
G. WILL PROPOSED ACTIVITY CAUSE FLOODING OR DRAINING OF WETLANDS? DYES 0 NO
IF YES. IMPACTED AREA IS _ ACRES OFDRAINeD WETLANDS.
Dyes 0 NO
DYES 0 NO
NOTE: If your prOject will impacl greater than \oS of an acre of weiland. submil a miUgallon plan 10 the Cosps and Ecology for approval along wilh the JARPA form
.NOTE: a 401 waler qualily certification win be requiled (rom Ecology in adrJi/ion /0 an approved miNga/ion plan if yOur project impacts wellands Iha/ alll: a) greater Ihan ~ acre in s;ze, or
b) tidal we/lands or we/lands arQacenl/o /idal waler. Please submit/he JARPA form and mitigation plan /0 ECOlogy for an IrldMdual401 cef/jfjcalion if a) or b) applies.
12. STORMWATERCOMPL.IANCE FOR NATIONWIDE PERMITS ONLY; N/A
THIS PROJECT IS (OR WILL BE) DESIGNED TO MEET ECOLOGY'S MOST CURRENT STORMWA TER MANUAL. OR AN ECOLOGY APPROVED LOCAL STORMWA TER MANUAL YES 0 NO
IF YES - WHICH MANUAL WIL.L. YOUR PROJECT BE DESIGNED TO MEET
If NO- FOR CLEAN WATER ACT SECTION 401 AND 404 PERMITS ONL Y - PL.EASE SUBMITTO ECOLOGY FOR APPROVAL. ALONG WITH THIS JARPA APPLICATION, DOCUMENTATION THAT
JARP A, Revised 7/02 Contact the State of Washington Office of Permit Assistance for latest version, 360/407-7037 or 800/917-0043
3
DEMONSTRATES THE STORMWA TER RUNOFF FROM VOU
ECT OR ACTIVITY WILL COMPL V WITH THE WATER QUALlTV
:ARDS. WAC 173.201(A)
13. WILL EXCAVATION OR DREDGING BE REQUIRED IN WATER OR WETlANDS? No
IF YES:
A. VOLUME: (CUBIC YAROS)/AREA (ACRES)
B. COMPOSITION OF MATERIAL TO BE REMOVED:
DYES IRINO
C. DISPOSAL SITE FOR EXCAVATED MATERIAL:
D. METHOD OF DREDGING:
14. HAS THE STATE ENVIRONMENTAL POLICY ACT (SEPA) BEEN COMPLETED? YES [8]NO
SEPA lEAD AGENCY: Jefferson County SEPA DECISION: DNS, MONS, EIS. ADOPTION. EXEMPTION DECISION DATE (END OF COMMENT PERIOD): Pending
SUBMIT A COpy OF YOUR SEPA DECISION lETTER TO WDFW AS REQUIRED FOR A COMPLETE APPLICATION
15. UST OTHER APPLICATIONS, APPROVALS, OR CERTIFICATIONS FROM OTHER FEDERAL, STATE OR LOCAl AGENCIES FOR ANY STRUCTURES, CONSTRUCTION, DISCHARGES, OR OTHER
ACTIVITIES DESCRIBED IN THE APPLICATION (I.E., PRELIMINARY PLAT APPROVAL, HEALTH DISTRiCT APPROVAL, BUILDING PERMIT, SEPA REVIEW, FEDERAL ENERGY REGULATORY
COMMISSION LICENSE (FERC), FOREST PRACTICES APPLICATION, ETC.) ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL EXISTING WORK ON DRAWINGS.
NOTE: FOR USE WITH CORPS NATIONWIDE PERMITS, IDENTIFY WHETHER YOUR PROJECT HAS OR WILL NEED AN NPOES PERMIT FOR DISCHARGING WASTEWATER AND/OR STORMWATER.
TYPE OF APPROVAL
ISSUING AGENCY
IDENTIFICATION
NO.
DATE OF APPLICATION
DATE APPROVED COMPLETED?
Building Permit
Construction Plan Approval
Hydraulic Project Approval
SSDP - Primary UselType A Permit
Jefferson County
Jefferson County
WA State DFW
Jefferson County
June. 2005
June. 2005
Not yet filed
June 7, 2006
16. HAS A~ AGENCY DENIED APPROVAl FOR THE ACTIVITY YOU'RE APPLYING FOR OR FOR ANY ACTIVITY DIRECTLY RELATED TO THE ACTIVITY DESCRIBED
HEREIN? 0 YES xNO IF YES, EXPLAIN:
JARPA, Revised 7/02 Contact the State of Washington Office of Permit Assistance for latest version, 360/407-7037 or 800/917-0043
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SECT/ON B . Use for Shoreline and Corps of Engineers permits onlv:
17a. TOTAL COST OF PROJECT. THIS MEANS THE FAIR MARKET VAlUE OF THE PROJECT, INClUDING MATERIALS, LABOR. MACHINE RENTAlS, ETC. $20 million
17b. IF A PROJECT OR ANY PORTION OF A PROJECT RECEIVES FUNDING FROM A FEDERAL AGENCY, THAT AGENCY IS RESPONSIBLE FOR ESA CONSUlTATION. PLEASE INDICATE IF YOU
ILL RECEIVE FEDERAL. FUNDS AND WHAT FEDERAL AGENCY IS PROVIDlNG THOSE FUNDS. SEE INSTRUCTIONS FOR INFORMATION ON ESA"
EDERAL FUNDINIG DYES IIDNO IF YES, PLEASE USTTHE FEDERAL AGENCY
18, LOCAl. GOVERNMENT WITH JURISDICTION:
Jefferson County
19. FOR CORPS, COAST GUARD, AND DNR PERMITS, PROVIDE NAMES, ADDRESSES, AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS, lESSEES, ETC...
PLEASE NOTE: SHORaINE MANAGEMENT COMPLIANCE MAY REQUIRE ADDITIONAL NOTICE - CONSUL r YOUR LOCAL GOVERNMENT.
NAME ADDRESS PHONE NUMBER
See APO list
SECTION C - This section MUST be completed for any permit covered b this application
20. APPLICATION IS HEREBY MAOE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES OESCRIBED HEREIN. I CERTIFY THAT I AM FAMIUAR WITH THE
INFORMATION CONTAINED IN THIS APPLICATION, AND THAT TO THE BEST OF MY KNOWLEDGE AND aELIEF, SUCH INFORMATION IS TRUE, COMPLETE, AND
CCURATE. I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH
JS APPLICATION IS MADE. THE RIGHT TO ENTER THE ABOVl:-OESCRlBED LOCATION TO INSPECT THE PROPOSED, IN.PROGRESS OR COMPlETED WORK. I
AGREE TO START WORK QW AFTER AL.L NECESSARY PERMITS HAVE BEEN ReCEIVED.
SIIfNATURE O~T
~ ~~ 1
SIGNATURE OF AU~T
I HEREBY DESIGNATE Reid Middleton, nc.
TO ACT AS MY AGENT IN MATTERS RELATED TO THIS APPLICATION FOR PERM
I MUST SIGN THE PERMIT.
DATE
). I UNOERSTAND THAT IF A FEDERAL PERMIT IS ISst.JED,
~ l"1. lpv
I
18 U.S.C !j1001 provides lllal: Whoeyer,ln any mamer wilhin lhe Jurlsdic60n 01 any deparlmenl or'9 Y of I Unlled Slales knowingly lalsmas, conceals. or coven; up by any kick, scheme, 0( device a
malesia' lacl Of makes any lalse. rocllllous. 01 Iraudlllenl stalemenls Or represenlalions or makes Of uses se wti6ng or documenl knowing same 10 conlain anylillse. fiClitious, or Iraudulenl S1alement Of
entry, shall be fined 1101 more lhan 510,000 or l~sCN!d nol more !han 5 years or bDlh.
COMPLETED BY LOCAL OFFICIAL
A, Nature of the existing shoreline. (Describe type of shoreline, such as marine, stream, lake,lagoon, marsh, bog, swamp, flood
plain, floodway, delta; type of beach, such as accretion, erosion, high bank. low bank, or dike; material such as sand, gravel, mud, clay,
rock, riprap; and extent and type of bUlkheading, if any)
B. In the event that any of the proposed buildings or structures will exceed a height of thirty-five feet above the average grade
level, indicate the approximate location of and number of residential units, existing and potential, that will have an obstructed view:
C, If the application involves a conditional use or variance. set forth In full that portion of the master program which provides that
the proposed use may be a conditional use, or, in the case of a variance, from which the variance is being sought:
These Agencies are Equal Opportunily and Afflrmalive Action employers.
For special accommodation needs, please conlact lhe appropriale agency In the inslruclions.
JARP A, Revised 7/02 Contact the State of Washington Office of Permit Assistance far latest version, 360/407-7037 or 800/9 [7-0043
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SECTION B-Use for Shoreline and Corps of Engineers pennifS onrv;
17a. TOTAL COST OF PROJECT. THIS MEANS THE FAIR MARKET VALUE Of THE .PROJECT, INCLUDING MATERIALS,I.A8Of{, MACHINE RENTALS, ETC. $20 million
17/>. IF A PROJECT OR ANY PORTION OF A PROJECT RECEI\lES FUNDlNG FROM A F.eOERALAGENCY. THAT AGENCY IS RESPONSIBLE FOR ESA CONSULTATION. PLEASE INDiCATE .IF YOU
ILL RECEIVE FEDERAL FUNOS AND WHAT F.eDERAL AGENCY IS PROVIDING THOSE FUNDS. SEE iNSTRUCTIONS FOR INFORMATION ON ESA"
EDERALFUNDlNJ.G 0 YES IRINa IF YES. PLEASE LIST THE FEDERAL AGENCY
18. LOCAL GOVERNMENT WITH JURISDICTION:
Jefferson County
19. FOR CORPS. COAST GUARD, AND DNR PERMITS, .PROVIOE NAMES, ADDRESSES. AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS. LESSEES. erc...
PLEASE NOTE: SHORElJNE MANAGEMENT COMPUANCE MAY REQUIRE ADDriioNAL NOTiCE - CONSULT YOUR LOCAL GOVERNMENT.
NAME ADDRESS PHONE NUMBER
SECT/ON C - this section MUST be com leted for an permit covered by this application
20. APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES DESCRIBED. HEREIN. 1 CERTIFY THAT I AM FAMILIAR WITH THE
INFORMATION CONTAlNEO IN THIS APPlICATION. ANO THAT TO THE BEST OF MY KNOWlEOGEANO BeliEF, SUCH INFORMATION IS TRUE, COMPLETE, AND
CU . :fE. 'FURTHER CERTIfY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCies TO WH\CH
IS PLICATION IS MADE, THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED, IN-4'ROGRESS OR COMPLETED WORK. I
AGR ,TO START WORI< ~ AFTER ALL NECESSARY peRMITS HAVE BEEN RECEIVED.
SIGN DATE
19-1-o~
le
DATE
Reid Middleton, Inc.
TIERS RELATED TO THIS APPLICATION FOR PERM]TIS). I UNDeRSTAND THAT IF A FEDERAL PERMIT is ISSUEO.
DATE fo-1-0lQ
SIGNATURE OF LANDOWNER (EXCEPT PUBLIC ENTITY LANDOWNERS. E.G. ONRI
:.;.... ~.:""..~.'-'
..~...~...,.;;;
, ".::.,-
T, IF AN AUTHORize
18 U. S.C Ii 1001 provides Ihat WhOllver. In any manner within \he jurisdICtion or anydepar1m8lll or agency of iii Un Slales knowingly ralsifies. cont:eals, or covers up by any Irick, sch."",. or device a
matenal rael or make. any fain. ncuuous. or r"'uduhm'slalernenls or 'epresenlalions or makes or uses any Ie 'n9 or dcicumenl knowing same .10 conlain any false. ncliUous, or fraudulentslatem&nl or
ellvy. shall be filled nol more Ih;ln S10,IlOO or l.,.xfllOned nol morelhan 5 ye<ll'$ or both.
...... ..:....... ";.
;.;,;~.~~~~_i~}~~:'~.::fi~;::'FjJ:~:~!~:!;'.: '.::' ,,::.
These Agencies are Equal Opportunily and AffinnaUve Action employelS.
For special accommodation needs. please conlacllhe appropriate agency In the instruc1iOlls.
JARPA, Revised 7102 Contact the State of Washington Office qfpermit Assistance for latest vcrsioll, 3601407-7037 or 8QOJ9I 7-,QQ43
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