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Home My WebLink AboutSHX2024-00004 Bulkhead Repair - SHX Permit / Conditions - 3/13/2024 Mason County Planning Division of Community Development 615 W. Alder St. Building 8 41 Shelton, WA 98584 360-427-9670 ext 352 www.masoncountywa.gov FPROJECT 4-00004 SHORELINE EXEMPTION DESCRIPTION: BULKHEAD CRACK REPAIR ISSUED: 03/13/2024 ESS: 24050 N US HIGHWAY 101 HOODSPORT EXPIRES: 03/13/2029 PARCEL: 422132270585 APPLICANT: PARSONS JOEL&SUSAN OWNER: PARSONS JOEL&SUSAN PO BOX 22 PO BOX 22 WILKESON,WA 98396 WILKESON,WA 98396 206.948,5634 FEES: Paid Due PLA-SHORELINE EXEMPTION $300.00 $0.00 Totals : $300.00 $0.00 CONDITIONS A Hydraulic Project Approval from the Washington State Department of Fish and Wildlife must be granted prior to commencing work. wdfw.wa.gov * Landfill for residential development which results in the creation of new dry land waterward of OHWM or in biological wetlands is prohibited. * All construction debris must be removed from the site after project completion to an approved location. Proper disposal of construction debris must be on land in such a manner that debris cannot enter or cause water quality degradation of aquatic environments. * Approved per dimensions and setbacks on submitted site plan. Setbacks are measured from the furthest projection of the structure. * All other necessary permits from Mason County, Washington State, Federal Agencies, and/or other agencies/groups that are required for this proposed development and construction must be obtained PRIOR TO DEVELOPMENT AND CONSTRUCTION. * A Department of the Army permit shall be obtained prior to the performance of any activities waterward of the mean higher high water mark or ordinary high water mark or in wetlands. * Water quality is not to be degraded to the detriment of the aquatic environment as a result of this project including but not limited to concrete leachate containment. Printed by:Julie Cheney on:03/13/2024 08:32 AM Page 1 of 2 Mason County Ilk Planning Division of Community Development 615 W. Alder St. Building 8 Shelton, WA 98584 360-427-9670 ext 352 www.masoncountywa.gov SHORELINE EXEMPTION SHX2024-00004 * Proper erosion and sediment control practices must be used on the construction site and adjacent areas to prevent upland sediments from entering the aquatic environment. Erosion control measures must be in place prior to any clearing, grading, or construction. These control measures must be effective to prevent soil from being carried into surface water by stormwater runoff. Any discharge of sediment-laden runoff or other pollutants to waters of the state is in violation of state regulations. Any work in or adjacent to waterways that will adversely affect water quality must receive specific prior authorization from the Department of Ecology. Silt fencing, straw matting, etc. must be installed and maintained until seeding or upland vegetation has become established around all areas disturbed or newly created by construction activities. * No waterward expansion. No structures to be built on top of bulkhead or landward of bulkhead without further permitting. Permit is for repair only; cannot replace bulkhead without further review. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of Laws and Ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state/local law regulating construction or the performance of construction. Issued By: I 3- a Lf Contractor or Authorized Agent: Date: Printed by:Julie Cheney on:03/13/2024 08:32 AM Page 2 of 2 4Fur. ;--- -------RECEIVED------ j`r AGENCY USE ONLY ' l � US Army =J WASHINGTON STATE ofea ngin Corps Date received: FEB 13 2024 of Engineers Sttle DietrlCl � Joint Aquatic Resources Permit ,nI q Agency re 1pee. Alder Ptreet Application (JARPA) Form' 2 [he,,), 5Nx 22)1 &WJ USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. Tax Parcel#(s):4,�ui-,72—,;?;L z laa3 l I l 1 , L--------------------------------------1 Part 1-Project Identification 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) hel Parsons Hoodsport site Part 2-Applicant The person and/or organization responsible for the project. [hell 2a. Name(Last, First, Middle) Parsons Joel Jay 2b. Organization(If applicable) Owner 2c. Mailing Address (Street or PO Box) PO BOX 22 2d. City, State, Zip Wilkerson WA 98396 2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail 206 948 5634 Joel@Rivertoncontractors.corr '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(206)764-3495. • Not all cities and counties accept the JARPA for their local Shoreline permits.If you need a Shoreline permit,contact the appropriate city or county government to make sure they accept the JARPA. 2To access an online JARPA form with[help]screens,go to http://www.er)ermitting.wa.gov/site/alias resourcecenter/lama iarpa form/9984/iarpa form.aspx. For other help,contact the Governor's Office for Regulatory Innovation and Assistance at(800)917-0043 or help(aD-oria.wa.gov. ORIA-revised 0212020 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.) [help] 3a. Name (Last, First, Middle) 3b. Organization (If applicable) 3c. Mailing Address (street or PO Box) 3d. City, State, Zip 3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail Part 4-Property Owner(s) Contact information for people or organizations owning the property(ies) where the project will occur. Consider both upland and aquatic ownership because the upland owners may not own the adjacent aquatic land. [help] ID Same as applicant. (Skip to Part 5.) ❑ Repair or maintenance activities on existing rights-of-way or easements. (Skip to Part 5.) ❑ There 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) 4d. City, State, Zip 4e. Phone(1) 4f. Phone(2) 4g. Fax 4h. E-mail ORIA-revised 02/2020 Page 2 of 14 Part 5—Project Location(s) Identifying information about the property or properties where the project will occur. [help] ❑ There are multiple project locations (e.g. linear projects). Complete the section below and use JARPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (Check all that apply.) hem 1] 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.) help) 24050 N HWY 101 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) hem Hoodsport WA 98548 5d. County help] Mason 5e. Provide the section, township, and range for the project location. !2elp) 1/4 Section Section Township Range 13 22N 4W 5f. Provide the latitude and longitude of the project location. hel • Example:47.03922 N lat./-122.89142 W long. (Use decimal degrees-NAD 83) 47.403 lat. / -123.142 5g. List the tax parcel number(s)for the project location. [Leipj • The local county assessor's office can provide this information. 42213-22-70585 5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) [hell ) Name Mailing Address Tax Parcel #(if known) Lopez Et Alvaro Edelmira Garcia 258 E Springfield Loop 42212-33-00010 Del Lopez ................__..._....... ........- .. __ __........_._........... .. Shelton WA 98584 CEB LLC 2414 SW Andover ST #F102 42213-22-70584 .. .. ........ _ ..... % Sue Fone Seattle WA 98106 ORIA-revised 0212020 Page 3 of 14 51i. List all wetlands on or adjacent to the project location. w 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. nei Hood Canal 5k. Is any part of the project area within a 100-year floodplain? hLeip] 121 Yes ❑ No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. hf e Site is on extremely small shoreline lot backed by HWY 101 N No Native Vegetation 5m. Describe how the property is currently used. h[ eM Needs to be repaired 5n. Describe how the adjacent properties are currently used. hei Commercial 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. [Leipj The lot supports remnants of a commercial building, including an approx. fifty-two-foot (length) by six feet (height) concrete bulkhead, an approx. eleven by twenty-three-foot (1 V x 23') protruding concrete bulkhead section (253 sf), and six concrete and rebar pilings. 5p. Provide driving directions from the closest highway to the project location, and attach a map. tgipi From Shelton, take SR 101 North. The site is located on the waterfront, adjacent a Mexican food restaurant in Hoodsport ORIA-revised 02/2020 Page 4 of 14 Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. [help] Repair a small hole in concrete bulkhead, and area of five inches by 15 inches (5" x 15"). A very small project. Two bags of ready mix concrete, placed to refill area 6b. Describe the purpose of the project and why you want or need to perform it. [help] This work needs to be done, so future work can be done. I had Lizzie Carp (ECY) investigate the situation. After her review she concluded it is "normal repair and maintenance". She referred me too Julie Cheney at the county. This is needed for me to proceed, per Julie Cheney 6c. Indicate the project category. (check all that apply) [help] III Commercial ❑ Residential ❑ Institutional ❑ Transportation ❑ Recreational ❑ Maintenance ❑ Environmental Enhancement 6d. Indicate the major elements of your project. (check all that apply) [help] ❑ Aquaculture ❑ Culvert ❑ Float ❑ Retaining Wall ❑ Bank Stabilization ❑ Dam /Weir ❑ Floating Home (upland) ❑ Boat House ❑ Dike/ Levee / Jetty ❑ Geotechnical Survey ❑ Road ❑ Boat Launch ❑ Ditch ❑ Land Clearing ❑ Scientific Measurement Device ❑ Boat Lift ❑ Dock / Pier ❑ Marina / Moorage ❑ Stairs ❑ Bridge ❑ Dredging ❑ Mining ❑ Stormwater facility ❑ Bulkhead ❑ Fence ❑ Outfall Structure ❑ Swimming Pool ❑ Buoy ❑ Ferry Terminal ❑ Piling/Dolphin ❑ Utility Line ❑ Channel Modification ❑ Fishway ❑ Raft 111 Other: Minor concrete repair (grouting) less than 3 hours of work ORIA-revised 0212020 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. [help] • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year floodplain. existing concrete bulkhead has a small hole and needs to be repaired. Two sacks of ready mix concrete and less than three hours of work. Activities are within the 100-year flood plain. The nearest waterway is Hood Canal 6f.What are the anticipated start and end dates for project construction? (MonthNear) [help] • If the project will be constructed in phases or stages, use JARPA Attachment D to list the start and end dates of each phase or stage. Start Date: unknown End Date: ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. n[ eM $ 300.00 61h. Will any portion of the project receive federal funding? n[hei ] • If yes, list each agency providing funds. ❑ Yes 0 No ❑ Don't know 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.) neI 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. LLei2j ❑ Not applicable 7b. Will the project impact wetlands? ne[p]I ❑ Yes ❑ No ❑ Don't know 7c.Will the project impact wetland buffers? LkV ❑ Yes ❑ No ❑ Don't know ORIA-revised 02/2020 Page 6 of 14 7d. Has a wetland delineation report been prepared? [help] • If Yes, submit the report, including data sheets,with the JARPA package. ❑ Yes ❑ No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? h[ elp] • If Yes, submit the wetland rating forms and figures with the JARPA package. ❑ Yes ❑ No ❑ Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? h[ elal • If Yes, submit the plan with the JARPA package and answer 7g. • 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. [help] 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. [help] Activity (fill, Wetland Wetland Impact Duration Proposed Wetland drain, excavate, Name' type and area (sq. of impact3 mitigation mitigation area flood, etc.) rating ft. or type' (sq. ft. or category2 Acres) acres) If no official name for the 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. 'Indicate the days,months or years the wetland will be measurably impacted by the activity.Enter"permanent"if applicable. `Creation C,Re-establishment/Rehabilitation R,Enhancement E,Preservation P, Mitigation Bank/ln-lieu fee B Page number(s) for similar information in the mitigation plan, if available: ORIA-revised 0212020 Page 7 of 14 7i. 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. [heipl 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. [help] 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.) [help] ❑ 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. hel ❑ Not applicable Repair can be done under three hours, at the proper tide. Extreme high tide, is the only situation that would effect this repair. Best Management Practices, Washington Department of Fish and Wildlife's Hydraulic Project Approval (HPA) stipulations to be strictly adhered to. 8b. Will your project impact a waterbody or the area around a waterbody? [help] ID Yes ❑ No ORIA-revised 0212020 Page 8 of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? heI • If Yes,submit the plan with the JARPA package and answer 8d. • If No,or Not applicable,explain below why a mitigation plan should not be required. ❑ Yes 121 No ❑ Don't know Simple maintenance 8d. Summarize what the mitigation plan is meant to accomplish. Describe how a watershed approach was used to design the plan. • If you already completed 7g you do not need to restate your answer here. [help] 8e. Summarize impact(s) to each waterbody in the table below. h[ elpl Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location' of impact' (cubic yards) to be linear ft.) of drive, etc.) placed in or removed waterbody from waterbody directly affected Hood Canal pper shorelirs than 3 hot .0074 CYS .52 sq. ft. 'If no official name for the waterbody exists,create a unique name(such as"Stream 1")The name should be consistent with other documents provided. 2 Indicate 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. 3 Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"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. h[ elp] .0074 CYS of concrete. Placed "by hand" AKA "Grouting". This will be done during the correct tide. Extreme high tide, is the only time water would effect this work. ORIA-revised 02/2020 Page 9 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. [help] N/A 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. [help] Agency Name Contact Name Phone Most Recent Date of Contact WA Dept Ecology Lizzie Carp 564 200 4184 11/8/23 Mason County Julie Cheney 360 490 9670 11/30/23 I 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? [help] • If Yes,list the parameter(s)below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: https://ecologv.wa.gov/Water- Shoreli nes/Water-g ual itv/Water-improvement/Assessment-of-state-waters-303d. 121 Yes 121 No 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? [help] • Go to http://cfpub.epa.goy/surf/locate/index.cfm to help identify the HUC. 17110018 9d. What Water Resource Inventory Area Number (WRIA#) is the project in? [tg-lPj • Go to https://ecology.wa.govfWater-Shorelines/Water-supply/Water-availability/Watershed-look-up to find the WRIA#. WRIA 16 ORIA-revised 02/2020 Page 10 of 14 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? [help] • Go to https://ecology.wa.gov/Water-ShorelinesANater-quality/Freshwater/Surface-water-quality-standards/Criteria for the standards. ❑ Yes ❑ No 0 Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? Ihelpj • If you don't know, contact the local planning department. • For more information, go to: https://ecology.wa.gov=ater-Shorelines/Shoreline-coastal-management/Shoreline-coastal- planning/Shoreline-laws-rules-and-cases. ❑ Urban ❑ Natural ❑ Aquatic ❑ Conservancy 0 Other: Minor concrete repair (grouting) 9g. What is the Washington Department of Natural Resources Water Type? [help) • Go to http://www.dnr.wa.gov/forest-practices-water-typing for the Forest Practices Water Typing System. 0 Shoreline ❑ 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? [help] • If No, provide the name of the manual your project is designed to meet. El Yes ❑ No Name of manual: Stormwater Management Manual for Western Washington 9i. Does the project site have known contaminated sediment? [help] • If Yes, please describe below. ❑ Yes 0 No 9j. If you know what the property was used for in the past, describe below. hel It was a forest 9k. Has a cultural resource (archaeological) survey been performed on the project area? h[ elpl • If Yes, attach it to your JARPA package. ❑ Yes 0 No ORIA-revised 02/2020 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. of eid In the action area, there are four species listed under the Endangered Species Act by the U.S. Fish and Wildlife Service (USFWS) as threatened species. The bull trout(Salvelinus confluentus), marbled murrelet (Brachyramphus marmoratus), streaked horned lark(Eremophila alpestris strigata), and yellow-billed cuckoo (Coccyzus americanus) are listed as threatened and critical habitat has been designated for the former three species. The action area includes critical habitat for the bull trout. Two other species in the project area are listed as proposed. The fisher (Martes pennanti)is listed as proposed threatened, and the Dolly Varden (Salvelinus malma)is listed as proposed under the ESA"similarity of appearance" provision. In the action area, there are nine species listed under the Endangered Species Act by the National Marine Fisheries Service (NMFS) as either threatened, endangered, or candidate species. The humpback whale, Bocaccio, and leatherback turtle, are listed as endangered, while the Puget Sound Chinook salmon.Puaet Sound steelhead. Hood Canal summer-run chum salmon. areen sturaeon. 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 The Washington Deptment of Fish and Wildlife publishes a Priority Habitats and Species list and a Species of Concern list. The PHS list includes habitats, species groups considered to be priorities for conservation and management. The project site is categorized as one of those habitat types-Marine/Estuarine Shoreline. WDFW data revealed that three other species of anadromous salmonids on the Stae's PHS list may be found within the action area: Puget Sound?Strait of Georgia Chum salmon, Puget Sound coho salmon, the pink salmon, the sockeyesalmon, and the Puget Sound/Coastal cutthroat. The Puget Soundcoho salmon is also an ESA listed Species of Concern. Species of Concern are not species that are being actively considered for listing under the ESA by the NMFS or FWS. They have been identified as Species of concern because of concerns or great uncerttainties regarding biological status and threats. Part 10—SEPA Compliance and Permits Use the resources and checklist below to identify the permits you are applying for. • Online Project Questionnaire at http://apps.oria.wa.gov/opas/. • Governor's Office for Regulatory Innovation and Assistance at (800) 917-0043 or help(cD-oria.wa.gov. • For a list of addresses to send your JARPA to, click on agency addresses for completed JARPA. 10a. Compliance with the State Environmental Policy Act (SEPA). (Check all that apply.) hf @M • For more information about SEPA, go to hftps://ecology.wa.gov/regulations-permits/SEPA-environmental-review. ❑ A copy of the SEPA determination or letter of exemption is included with this application. ❑ A SEPA determination is pending with (lead agency). The expected decision date is ❑ 1 am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 1 ob.) hr elpl 121 This project is exempt (choose type of exemption below). ❑ Categorical Exemption. Under what section of the SEPA administrative code (WAC) is it exempt? ❑ Other: ❑ SEPA is pre-empted by federal law. ORIA-revised 02/2020 Page 12 of 14 1 Ob. Indicate the permits you are applying for. (Check all that apply.) h[ e LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance Z Shoreline Exemption Type (explain): Other City/County permits: ❑ Floodplain Development Permit El Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: 0 Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form Washington Department of Natural Resources: ❑ Aquatic Use Authorization Complete JARPA Attachment E and submit a check for$25 payable to the Washington Department of Natural Resources. Do not send cash. Washington Department of Ecology: ❑ Section 401 Water Quality Certification ❑ Non-Federally Regulated Waters FEDERAL AND TRIBAL GOVERNMENT United States Department of the Army (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) Il Section 10 (work in navigable waters) United States Coast Guard: For projects or bridges over waters of the United States, contact the U.S. Coast Guard at: d13-pf-d13bridges@uscg.miI ❑ Bridge Permit ❑ Private Aids to Navigation (or other non-bridge permits) 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-revised 02/2020 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. heI 11 a.Applicant Signature (required) hf em 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 carry 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 ate that I have the authority to grant access to the property. I also give my consent to the permitting agencies entering the property where the project is located to inspect the project site or any work related to the project. itial) Joel Parsons .7"-6 par;~ 12/04/23 Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature [hell 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 carry out the proposed activities and I agree to start work only after all necessary permits have been issued. Authorized Agent Printed Name Authorized Agent Signature Date 11c. Property Owner Signature (if not applicant) h[ elpl Not required if project is on existing rights-of-way or easements (provide copy of easement with JARPA). 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. Property Owner Printed Name Property Owner Signature Date 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 than 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. 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