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HomeMy WebLinkAboutSHX2016-00034 JARPA Boat Rail - SHX Application - 5/18/2016 �PS�N STAT��o MASON COUNTY n�C DEPARTMENT OF COMMUNITY DEVELOPMENT o A , = Planning Division - o T z 615 W Alder St, Shelton, WA 98584 N Y Cc) (360)427-9670 OJ *11O 1864 Exemption from Shoreline Management Act Case No.: SHX2016-00034 Substantial Development Permit Requirement The Proposal By: STEN J. KARLSEN 13704 68TH AVE W EDMONDS, WA 98026 To undertake the following development: KARLSEN BOAT RAIL Within HOOD CANAL and/or its associated wetlands is exempt from the requirement of substantial development because the development is categorized under WAC 173-27-040(2) as being category A-does not exceed dollar threshold Please contact Kell McAboy at ext 365 if you have any questions. k' _V_ _Q�� (Z> — , Issued: 5/18/2016 Expires: 5/18/2018 Authorized Local Government Offi i cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL ---------------------------------------- AGENCY USE ONLY Date received: — j" c,W 1 69 US Army Corps i WASHINGTON STATE °�E^g'°°er°� s••+n• Agency reference#: Joint Aquatic Resources Permit Application (DARPA) Form' 2 LelpjTax Parcel#(s): USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. -------------------------------------- RECEIVED MAY 13 2016 Part 1—Project Identification 615 W. Alder Street 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) h[W Karlsen Boat Rail Part 2—Applicant The person and/or organization responsible for the project. h[ eM 2a. Name (Last, First, Middle) Karlsen, Sten J. 2b. Organization (If applicable) N/A 2c. Mailing Address (Street or PO Box) 13704 68t'Ave W 2d. City, State, Zip Edmonds, WA 98026 2e. Phone(1) 2f. Phone(2) 2g. Fax 2h. E-mail (425) 582-1585 (425) 742-6698 ( ) sten.karlsen@gmail.com lAdditional 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. • If your project might affect species listed under the Endangered Species Act,you will need to fill out a Specific Project Information Form(SPIF)or prepare a Biological Evaluation. Forms can be found at http://www nws usace army mil/Missions/Civi(Works/Regulatory/PermitGuidebook/EndanoeredSr)ecies aspx. • 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.ei)ermitting.wa.gov/site/alias resourcecenterharpa iarpa form/9984/jarpa form aspx. For other help,contact the Governor's Office for Regulatory Innovation and Assistance at(800)917-0043 or help .oria.wa.gov. JARPA Revision 2015.1 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) Pickard, Jeff 3b. Organization (If applicable) Rimrock Builders, Inc 3c. Mailing Address (street or Po Box) PO Box 3814 3d. City, State, Zip Silverdale, WA 98383 3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail ( 360) 479-1820 ( 360) 340-7264 ( ) pickardconstruction@hotmail.com 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. hel X 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) Karlsen, Sten J. 4b. Organization,(If applicable) 4c. Mailing Address (Street or Po Box) 13704 681h Ave W 4d. City, State, Zip Edmonds, WA 98026 4e. Phone(1) 0. Phone(2) 4g. Fax 4h. E-mail (425) 582-1585 (425) 742-6698 ( ) sten.karlsen@gmail.com JARPA Revision 2015.1 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 JARPA Attachment B for each additional project location. 5a. Indicate the type of ownership of the property. (check all that apply.) of ela] X 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.) [hel 12881 NE North Shore Rd 5c. City, State, Zip (If the project is not in a city or town, provide the name of the nearest city or town.) h[ elpl Belfair, WA 98528 5d. County hei Mason --------- -- -------------- 5e. Provide the section, township, and range for the project location. h[_elp] 1/4 Section Section Township Range T22N R03W 5f. Provide the latitude and longitude of the project location. n[ eAi • Example:47.03922 N lat./-122.89142 W long. (Use decimal degrees- NAD 83) 47.359361 N lat. / 123.038983 W long. 5g. List the tax parcel number(s) for the project location. h[ elp� • The local county assessor's office can provide this information. 32234-50-00010 5h. Contact information for all adjoining property owners. (if you need more space, use JARPA Attachment C.) hel Name Mailing Address Tax Parcel # (if known) 12861 NE Northshore Rd 32234-50-00008 ............._......_.._......................................._...... ..._........_..... ----.._....._- David Keith Matthews ET AL Belfair, WA 98528 12901 NE Northshore Rd 32234-50-00012 Matthew J & Karen G Eschbach Belfair, WA 98528 ........... -----..--__._..___.___._...__...__..._._... .................. _.-. JARPA Revision 2015.1 Page 3 of 14 5i. List all wetlands on or adjacent to the project location. el N/A 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. h[ el Hood Canal on south side of property 5k. Is any part of the project area within a 100-year floodplain? hel ❑ Yes X No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. hf�] Existing yard has established landscaping including plants, trees, and a small lawn. The project of installing boat rails and piers will be conducted on the portion of the property that only has a surface of a gravel beach with no vegetation. 5m. Describe how the property is currently used. hei Residential home originally built in 1939 and used as a second home and recreational beach. 5n. Describe how the adjacent properties are currently used. hei All adjacent homes are used as second homes. 5o. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. hei Well maintained home includes retaining wall and bulk head with steps to the beach. The property is considered low-bank access. 5p. Provide driving directions from the closest highway to the project location, and attach a map. hel Drive approximately 12.8 miles from Highway 3 in Belfair on NE North Shore Road to address 12881 NE North Shore Road on the south side of the road. JARPA Revision 2015.1 Page 4 of 14 Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. hf elp] Hand dig and install 8" HDPE plastic pipe, the round columns will stand vertical and will have concrete poured into the pipe. The pipe will act as forms and contain the concrete. The round concrete columns will support the boat rails. 6b. Describe the purpose of the project and why you want or need to perform it. hf eiP� Install 8"x3' plastic HDPE pipe. The pipe will be dug and buried vertical on the beach (and act as forms to pour round concrete piers). The piers will be height will be at least 13" to 14" above existing gravel to beach. Install boat rails by attaching on top of columns using stainless steel hardware. Purpose is to launch and remove boat from Hood Canal the same way as two neighbors adjacent to our property (Parcels 32234-50-00013, 32234-50-00014). Boat rail design is identical in design to neighbors project (SHX2013-00043) with exception of using a total of 10, eight inch diameter piers per rail instead of neighbor's total of 8, twelve inch diameter piers, allowing my project to have less total area pier space. 6c. Indicate the project category. (check all that apply) hf elpl ❑ Commercial X Residential ❑ Institutional ❑ Transportation X 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 X Boat LA (Rail) ❑ 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 X Other: Installing concrete piers to support boat rails (pour concrete into HDPE plastic pipe) JARPA Revision 2015.1 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. hel • Identify where each element will occur in relation to the nearest waterbody. • Indicate which activities are within the 100-year floodplain. Using Best Management Practices (BMP) —Weather and Tide Charts will be used to determine lowest tide. By using the HDPE plastic pipe, we will be able to set the columns by hand digging and complete in one day. We would pour the next morning at low tide first the columns nearest the water. This would allow them to cure, the concrete mix will be quick set and will be covered in 6 mil plastic. All concrete will be contained inside the plastic pipe forms and not concrete will be spilled or allowed on the beach. After the concrete has cured we will install the rails. Hood Canal is adjacent to the project. 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:6/15/2016 End date:9/15/2016 ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. hf eM Value of project $ 3,900 6h. Will any portion of the project receive federal funding? hel • If yes, list each agency providing funds. ❑ Yes X 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.) h[ eid 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. ht eipl X Not applicable 7b. Will the project impact wetlands? LheM ❑ Yes X No ❑ Don't know 7c. Will the project impact wetland buffers? hf d JARPA Revision 2015.1 Page 6 of 14 ❑ Yes X No ❑ Don't know 7d. Has a wetland delineation report been prepared? hf elpl • If Yes,submit the report, including data sheets,with the JARPA package. ❑ Yes X No 7e. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? hel • If Yes, submit the wetland rating forms and figures with the JARPA package. ❑ Yes X No ❑ Don't know 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? hel • 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 X Not applicable N/A 7g. Summarize what the mitigation plan is meant to accomplish, and describe how a watershed approach was used to design the plan. hf elpl N/A 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 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. 3Indicate 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: JARPA Revision 2015.1 Page 7 of 14 7L 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. h[ elpj N/A 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. hel N/A 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.) hf eM X 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 Round pier column supports are designed at 8" diameter to minimize surface area and limiting the depth required for the piers; all the digging will be done by hand to a 2' depth and all the displacement material will be raked out around the plastic vertical column forms. Also, using the round column HDPE plastic pipe protects the life of the concrete inside instead and allows the natural movement of gravel on the beach to occur. The weather and tide charts will be used to determine the lowest tide and ideal conditions. Best Management Practices will be conducted at all times and the concrete mix design will be a quick set. Digging and concrete work will be done by the same contractor as boat rails at neighbors project (SHX2013-00043) using previous experience to ensure best results. 8b. Will your project impact a waterbody or the area around a waterbody? h[ elid X Yes ❑ No JARPA Revision 2015.1 Page 8 of 14 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? h( ell • 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 ❑ No X Not applicable 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. h[ elp] After the project is complete will 1) remove 120 square foot raft from beach and 2) reseed the beach with clams from Taylor Shellfish Company. Also I will then not need to apply anti-fouling paint to the bottom of our boat to prevent growth of organisms on the boat. Anti-fouling paint is potentially damaging to the environment and I will use the boat rail to pull the boat out of the water between uses instead to prevent organism growth on the boat. 8e. Summarize impact(s) to each waterbody in the table below. h[U Activity (clear, Waterbody Impact Duration of Amount of material Area (sq. ft. or dredge, fill, pile name' location impactt3 (cubic yards) to be linear ft.) of drive, etc.) placed in or waterbody removed from directly affected waterbody 1. Hand dig and Hood Canal 50' from Permanent No material will be One sq ft per install 8" high water removed. All gravel column, a total of diameter plastic mark (.51 cubic yard total) 20 columns =20 pipe forms will be raked around sq ft columns 1. Pour concrete .76 cubic yard of into plastic pipe concrete total will be forms used to fill all 20 piers. 2. Install boat Permanent 50' of railing railings 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. 'Indicate the days,months or years the waterbody will be measurably impacted by the work. Enter"permanent"if applicable. JARPA Revision 2015.1 Page 9 of 14 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. hel The concrete will be poured/pumped into vertical HDPE plastic pipe 8" diameter and 3' long, 13" to 14" of the pipe will be above the existing beach elevation to allow for natural movement of gravel. Approximately .51 cubic yard of gravel will be removed during the setting process of the 20 pier pipes and will be spread evenly by hand raking around the columns where the gravel displacement occurred. Approximately .76 cubic yard of concrete will fill the plastic pipe and become the new pier columns for supporting the boat rail total length of 50' from high water mark towards the canal- direction to the south. 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. Mid Pier columns are going to be dug 2' deep, by the method used will be manual post hole digger and shovel as tooling. The gravel will be left on site near the hole and spread out evenly with a rake. Either the concrete will be pumped by a line pump or hand carried in buckets and the concrete will be already mixed at the plant and delivered by truck to the address then pumped to the rear of the house. 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. h[ elpJ Agency Name Contact Name Phone Most Recent Date of Contact Wash Fish and Wildlife Joshua Benton (360) 602-0364 12/10/2015 Mason County Allan Borden (360) 427-9670 11/6/2015 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 303(d) List? h( ep] • If Yes, list the parameter(s) below. • If you don't know, use Washington Department of Ecology's Water Quality Assessment tools at: http://www.ecy.wa.gov/programs/wq/303d/. X Yes ❑ No Hood Canal (south) Category 5-303d (Assessed sediments and assessed water) JARPA Revision 2015.1 Page 10 of 14 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? hl elp] • Go to http://cfi)ub.epa.gov/surf/locate/index.cfm to help identify the HUC. 17110018 9d. What Water Resource Inventory Area Number (WRIA#) is the project in? h[ elp] • Go to http://www.ecy.wa.gov/services/gis/maps/wria/wria.htm to find the WRIA#. WRIA#15 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? hf elp] • Go to http://www.ecy.wa.gov/programs/wg/swgs/criteria.htmi for the standards. ❑ Yes ❑ No X Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? hel • If you don't know, contact the local planning department. • For more information, go to: http://www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations.html. ❑ Rural X Urban ❑ Natural X Aquatic ❑ Conservancy ❑ Other 9g. What is the Washington Department of Natural Resources Water Type? he[k ] • Go to http://www.dnr.wa.gov/forest-practices-water-typing for the Forest Practices Water Typing System. X 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? hf elpl • If No, provide the name of the manual your project is designed to meet. X Yes ❑ No Name of manual: ------- - -_-- - --- - 9i. Does the project site have known contaminated sediment? nel -- • If Yes, please describe below. - ❑ Yes X No 9j. If you know what the property was used for in the past, describe below. t1eI ] This property has been used as a vacation and second home including swimming, boating, fishing and recreational beach use for the last 77 years. 9k. Has a cultural resource (archaeological) survey been performed on the project area? h( eld • If Yes,attach it to your JAR PA package. r-E-1 Yes X No --- ---- - JARPA Revision 2015.1 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. hl M None 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. h[ ems] Salmon and Smelt during spawning period. 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(aD-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.) [help] • For more information about SEPA, go to www.ecywa.gov/programs/sea/sepa/e-review.html. ❑ A copy of the SEPA determination or letter of exemption is included with this application. X A SEPA determination is pending with Mason County (lead agency). The expected decision date is ❑ I am applying for a Fish Habitat Enhancement Exemption. (check the box below in 10b.) h( elp� ❑ 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. JARPA Revision 2015.1 Page 12 of 14 i 10b. Indicate the permits you are applying for. (Check all that apply.) hel LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance X Shoreline Exemption Type (explain): Boat Rails \ta'ky&`nab, Other City/County permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: .6 Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form You must submit a check for $150 to Washington Department of Fish and Wildlife, unless your project qualifies for an exemption or alternative payment method below. Do not send cash. Check the appropriate boxes: ❑$150 check enclosed. Check# Attach check made payable to Washington Department of Fish and Wildlife. ❑My project is exempt from the application fee. (Check appropriate exemption) ❑ HPA processing is conducted by applicant-funded WDFW staff. Agreement# ❑ Mineral prospecting and mining. ❑ Project occurs on farm and agricultural land. (Attach a copy of current land use classification recorded with the county auditor,or other proof of current land use.) ❑ Project is a modification of an existing HPA originally applied for, prior o to July 10, 2012. HPA# 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 FEDERAL GOVERNMENT United States Department of the Army permits (U.S. Army Corps of Engineers): ❑ Section 404 (discharges into waters of the U.S.) ❑ Section 10 (work in navigable waters) United States Coast Guard permits: ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2015.1 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. hf e 1la. Applicant Signature (required) h[ eipa 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. SaK (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 property where the project is located to inspect the project site or any work related to the project. (initial) AlA Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature h[ ei j 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 11 c. Property Owner Signature (if not applicant) hel Not required if project is on existing rights-of-way or easements. 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. ORIA publication number: ENV-019-09 rev. 09/2015 JARPA Revision 2015.1 Page 14 of 14