The URL can be used to link to this page

Home My WebLink AboutSHX2013-00043 JARPA - SHX Application - 8/16/2013 SON_STA MASON COUNTY �P .0 DEPARTMENT OF COMMUNITY DEVELOPMENT sa i Planning Division o N T = P O Box 279, Shelton, WA 98584 v y (360)427-9670 0 J � 1864 Exemption from Shoreline Management Act Case No.: SHX2013-00043 Substantial Development Permit Requirement The Proposal By: KOEHUBREEDEN 10505 118TH PL NE KIRKLAND, WA 98033 To undertake the following development: Proposed new boat rails on Hood Canal property; 5 ft. wide, and 20 ft. long above and 50 to 70 ft, forward of ordinary high water mark; set on short concrete piers. 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 $5,000 Please contact Allan Borden at ext 365 if you have any questio Issued: 8/16/2013 Expires: 8/16/2015 Authorized Local Government Official cc: APPLICANT WDFW USACOE WDOE TRIBAL COUNCIL --------------------------------------- AGENCY USE ONLY MDate received: .SUN 2 6 2013 WASHINGTON STATE US Army Corps of Engineers• t t Seattle DWO 426 W r!TA_R C " Joint Aquatic Resources Permit Agency reference#: SNX11)13-oQ7�F�J 1 2 s Application (JARPA) Form ° >: t Tax Parcel#( t t _ t t a t USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. t --------------------------------------- t i t t t t Part 1—Project Identification 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) hel Breeden-Koehl Boat Rail Part 2—Applicant The person and/or organization responsible for the project. [held 2a. Name (Last, First, Middle) Breeden, Brian, Charles 2b. Organization (If applicable) N/A 2c. Mailing Address (Street or PO Box) 10505 1181h PL NE 2d. City, State, Zip Kirkland, WA 98033 2e. Phone(1) 2f. Phone(2) 2 Fax 2h. E-mail (425) 518-3864 (425) 827-2517 HM ( ) BcBreeden@comcast.net 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. • 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 armv mil/Missions/CivirVVorks/Regulatory/PermitGuidebook/EndangeredSpecies.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.epermitting.wa.gov/site/alias resourcecenter/iarpa iarpa form/9984/6arpa form aspx. For other help,contact the Governor's Office of Regulatory Assistance at 1-800-917-0043 or help(Worama.gov. JARPA Revision 2012.1 Page 1 of 15 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.) of eM 3a. Name (Last, First, Middle) Pickard, Jeff 31b. Organization (If applicable) Pickard Construction Inc. 3c. Mailing Address (Street or Po Box) P.O Box 3814 3d. City, State, Zip Silverdale, WA 98383 3e. Phone(1) 3f. Phone(2) 3 . Fax 3h. E-mail (360) 340-7264 (360) 479-1820 HM ( ) Pickardconstioninc@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. neI 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) Breeden, Brian, Charles 4b. Organization (If applicable) 4c. Mailing Address (Street or Po Box) 10505 118th PL NE Northshore RD. 4d. City, State, Zip Belfair, WA, 98528 4e. Phone(1) 4f. Phone(2) 4 . Fax 4h. E-mail (425) 518-3864 (425) 827-2517 ( ) bcbreeden@comcast.net JARPA Revision 2012.1 Page 2 of 15 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.) hf elpl 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.) h[. elpJ 12921 NE Northshore RD 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) hel Belfair, WA 98528 5d. County hel Mason 5e. Provide the section, township, and range for the project location. hf elal '/4 Section Section Township Range 26 T22N R03W 5f. Provide the latitude and longitude of the project location. hf m • Example:47.03922 N lat./-122.89142 W long. (Use decimal degrees- NAD 83) 47.359092 lat. / 123. 039689 long. 5g. List the tax parcel number(s) for the project location. hf M • The local county assessor's office can provide this information. 32234-50-00014 5h. Contact information for all adjoining property owners. (If you need more space, use JARPA Attachment C.) hf eM Name Mailing Address Tax Parcel # (if known) Paul Ried 12941 NE Northshore RD 32234-50-00015 Belfair, Wa 98528 Jerry & Sue Brockman 12911 NE Northshore RD 32234-50-00014 Belfair, Wa 98528 JARPA Revision 2012.1 Page 3 of 15 5i. Lisf,all wetlands on or adjacent to the project location. n[ eld N/A 5.j. List all waterbodies (other than wetlands) on or adjacent to the project location. of elp) Hood Canal Beach on southside of property 5k. Is any part of the project area within a 100-year floodplain? hLe� ❑ Yes ;,No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. Lbgid Existing yard has established landscaping including the following; plants, trees, sod and mulch flower bed all northside of the bulk head. The project of installing boat rails and piers will be conducted on the portion of property that only has a surface of a gravel beach with no vegetation. 5m. Describe how the property is currently used. nei Residential home used as a second home and recreational beach, the original house was built in 1937 5n. Describe how the adjacent properties are currently used. nei All adjacent properties are currently used as second homes. 50. Describe the structures (above and below ground) on the property, including their purpose(s) and current condition. n[ M Well maintained home built in 2009, property 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. of elpl Drive West 13 miles from Highway 3 (Belfair) on the NE North Shore Road. Property is located at 12921 NE Northshore RD. Belfair, Wa 98528 on southside of road. JARPA Revision 2012.1 Page 5 of 15 Part 6—Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. hel Hand dig and install 12" HDPE-N12 plastic pipe, The round columns will stand vertical and will pour concrete 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. h[ eip] Install 12"x3' plastic HDPE-N12 pipe. The pipe will be dug and buried vertical on the beach (and acts as forms to pour Round concrete piers). The piers height will be 13 to 14" above existing gravel to beach (as requested by FISH AND WILDLIFE-"Margie Bigelow Shirato". Install boat rails by attaching on top of columns using stainless steel hardware. Why: Ability to launch and remove boat from Canal (Same way that the adjacent neighbor's use the rail system) 6c. Indicate the project category. (Check all that apply) h[ elp] ❑ 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 l RRIL ❑ Dock/ Pier ElMarina / 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 ADS plastic pipe) JARPA Revision 2012.1 Page 6 of 15 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-N12 plastic pipe, we will be able to set the columns by hand, digging and all in one day. We would pour the next morning first thing the columns nearest to the water. This would allow them to cure, the concrete mix design will be a quick set and will be covered in 6 mil plastic. All concrete will be contained inside the plastic pipe forms and no concrete will be spilled or allowed on the beach. After the concrete is 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) hei • 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: _6/15/2013 End date: _9/15/2013 ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. hf elal Value of project $ 2,800.00 6h. Will any portion of the project receive federal funding? hf eM • If yes, list each agency providing funds. ❑ Yes 56 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.) hel 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. hel tK Not applicable N/A 7b. Will the project impact wetlands? hf eM ❑ Yes Z,No ❑ Don't know 7c. Will the project impact wetland buffers? h[ M ❑ Yes X No ❑ Don't know JARPA Revision 2012.1 Page 7 of 15 7d. Has a wetland delineation report been prepared? h(—OA • If Yes, submit the report, including data sheets,with the JARPA package. ❑ Yes X No le. Have the wetlands been rated using the Western Washington or Eastern Washington Wetland Rating System? h[ eM • 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? 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 ® 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 eM 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. h[ elal 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. 4 Creation(C), Re-establishment/Rehabilitation(R), Enhancement(E), Preservation(P), Mitigation Bank/In-lieu fee(B) Page number(s) for similar information in the mitigation plan, if available: 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( ei A JARPA Revision 2012.1 Page 8 of 15 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. of eM 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.) nI elpl 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. h[ elpl ❑ Not applicable Round pier columns supports are designed by width size 12", which will not require to dig as deep. This will allow us to dig by hand only 2' deep and all the displacement of material will be raked out around the plastic vertical columns forms. Also, using round column HDPE-N12 plastic pipe protects the life of the concrete inside instead and allow 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 Practice will be conducted at all times and the mix design will be a quick set. 8b. Will your project impact a waterbody or the area around a waterbody? h[ elpp X Yes ❑ No JARPA Revision 2012.1 Page 9 of 15 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? hel • 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 B 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( elpl After the project is complete, will reseed the beach again with calms from Taylor Shellfish Company. 8e. Summarize impact(s) to each waterbody in the table below. hf eM 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 waterbody removed from directly affected waterbody 1.Hand dig-Install 1. Hood 1.50' from 1. 1. No Material will be 1. One sq.ft per plastic pipe Canal high water Permanent removed, All gravel column, a total forms mark to (.75 cubic yard). All of 14 columns canal gravel dug will be left planned= 14 raked around the sq.ft. each column. 2.Pour concrete 2.Pour 2. (1.25 cubic yard of Piers 14 piers concrete will be used to fill all (14) piers 3.Install boat 3. 50' of rails railing 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 2012.1 Page 10 of 15 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[ e�]i The concrete will be poured/pumped into vertical HDPE-N12 pipe 12" wide and 3' long, 13" to14" of the pipe will be above existing beach elevation to allow for natural movement of gravel. Approx .75 of cubic yard will be removed gravel from all (14) pier pipes during the setting process and will spread evenly, the excess of gravel by hand raking around the columns where the gravel displacement occurred. Approximate 1.25 cubic yards of concrete will bill plastic pipe and become the new piers columns for supporting of the boat rail total length 50' from high water mark towards 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. hf eid Piers Columns are going to be dug 2' deep, by the method used will be 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 mix 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. hel Agency Name Contact Name Phone Most Recent Date of Contact Wash. Fish & Wildlife Margie Bigelow Schirato (360) 793-9818 1/3/2013 Mason County Allan Borden (360) 427-9670 1/3/2013 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[ eM • 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/programsMq/303d/. ZC Yes ❑ No Hood Canal (South) Category 5-303d (assessed sediments and assessed water) JARPA Revision 2012.1 Page 11 of 15 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? LtLeM • Go to http://cfpub.epa.gov/surf/locate/index.cfm to help identify the HUC. 17110018 9d. What Water Resource Inventory Area Number (WRIA#) is the project in? heI • 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? h� eM • Go to http://www.ecy.wa. oq v/programs/wq/swas/criteria.html for the standards. ❑ Yes ❑ No U Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? hf eM • 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 )<Urban ❑ Natural tK Aquatic ❑ Conservancy ❑ Other 9g. What is the Washington Department of Natural Resources Water Type? h[ elp] • Go to http://www.dnr.wa.gov/BusinessPermits/Topics/ForestPracticesApplications/Pages/fp watertvping.aspx for the Forest Practices Water Typing System. 14 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 eIp] • If No, provide the name of the manual your project is designed to meet. Yes ❑ No Name of manual: 9i. Does the project site have known contaminated sediment? LhLeM • If Yes, please describe below. ❑ Yes 14 No 9j. If you know what the property was used for in the past, describe below. hf elpl This property has been used as a vacation and second home including swimming, fishing and recreational beach use for the last 76 years. 9k. Has a cultural resource (archaeological) survey been performed on the project area? hel • If Yes, attach it to your JARPA package. ❑ Yes X No JARPA Revision 2012.1 Page 12 of 15 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. hei 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. hel 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.ecy.wa.gov/opas/. • Governor's Office of Regulatory Assistance at (800) 917-0043 or help ora.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.) nel • For more information about SEPA, go to www.ecy.wa. ovcL /programs/sea/sega/e-review.html. ❑ A copy of the SEPA determination or letter of exemption is included with this application. XA 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.) hf elpl ❑ 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 2012.1 Page 13 of 15 10b. Indicate the permits you are applying for. (Check all that apply.) [tPjPJ LOCAL GOVERNMENT Local Government Shoreline permits: ❑ Substantial Development ❑ Conditional Use ❑ Variance Shoreline Exemption Type (explain): Boat Rails Other city/county permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: ❑ Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form Effective July 10, 2012, 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: P$150 check enclosed. (Check# SOS ) Attach check made payable to Washington Department of Fish and Wildlife. ❑Charge to billing account under agreement with WDFW. (Agreement # ) ❑ 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 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: ❑ General Bridge Act Permit ❑ Private Aids to Navigation (for non-bridge projects) JARPA Revision 2012.1 Page 14 of 15 Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. hel ;1a. 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 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. MAY (initial) ' Brian C. Breeden - / 0 /i Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature 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 all necessary permits have been issued. Jeff Pickard (Pickard Construction Inc) XZZLIL�__ 's / Authorized Agent Printed Name A onz Agent Signature Dat 11 c. Property Owner Signature (if not applicant). hf elpl 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 of Regulatory Assistance (ORA) 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. ORA publication number: ENV-019-09 rev. 06-12 JARPA Revision 2012.1 Page 15 of 15 MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT Building III—426 west Cedar Street P.O.Box 186, Shelton, WA 98584 (360)427-9670—Ext. 352 SHORELINE PERMIT APPLICATION PERMIT NO. SHORELINE SUBSTANTIAL DEVELOPMENT SHORELINE VARIANCE DATE RECEIVED SHORELINE CONDITIONAL USE X SHORELINE EXEMPTION The Washington State Shoreline Management Act (RCW 90.58) requires that substantial developments within designated shorelines of the state comply with its administrative procedures(WAC 173-14)and the provisions of the Mason County Shoreline Management Master Program. The purpose of this Act and local program is to protect the state's shoreline resources. The program requires that substantial development(any development of which the total cost or fair market value exceeds $5,000.00 or materially interferes with the normal public use of the water or shorelines of the State be reviewed with the goals, polices, and performance standards established in the Master Program. Answer all questions completely. Attach any additional information that my further describe the proposed development. Incomplete applications will be returned. APPLICANT: f✓�V ADDRESS: 105-0 S PL ME A/42 K4 AID (street) (city) (state) (zip) TELEPHONE: (home) ��rr (business) AUTHORIZED REPRESENTATIVE: pl C le4iZD e0AJ5 T11 VC T70 Al ADDRESS: (street)L.V�2D*6r , AJ,4 9 8'383 (city) (state) (ziP) TELEPHONE: C3lo L{Q"" 7oZ(� Ge q7,- AgZO µL PROPERTY DESCRIPTION: General location(include property address,water body and associated wetlands—identify the name of the shoreline);/OZ9o2� NE/�/D/17'f><s/�D/ �d 15 ov 5ouTf 51DE_ OF &-51DpYcg� ti/A7&-Z &by 15, Legal description (include section, township, and range to the nearest quarter, quarter section or latitude and longitude to the nearest minute. Projects located in open water areas away from land shall provide a longitude location)—include all parcel numbers: 1/7. 35_90 9a ° ZA7- — /�3. 03 96F9 4Z"6 (Sf471-0-,v zG 7'�/V /ao3k/) 10W404 :4�_ 3aa3V- .5a- 406/� OWNERSHIP: Contract Applicant X _ Owner Lessee Purchaser (Identify) Other Owner: l D .5-- ]Y-PL N le A LX033 (street) (city) (state) (zip) DEVELOPMENT DESCRIPTON Development(identify and describe the proposed project, including the type of materials to be used,construction methods,principle dimensions,and other pertinent information): V: 1// J2 �X 3 pLA1sT/e sll>s-�(/�L f7j,.lSTicr i°r%7JfE,%Ocr W111 Avg' /3urJEy I/�yi�rLr oN C3E�Kf�(P�v�A� �sr-o2ms To R�u.� Ro�,�� G�xRt�rF By Fsl��/GUrpGI`�: -/►�i�izq�E�il��Lor�S/�ir�-�. �sr�/l , R�-�/s 8y��1��'`'� Use(identify current use of property with exist improvements: 1z U4-W&H/Rr-YvwVE [30g-T hkw& cAN/i-& gv USi�yg 2,&1 lS ( SAmg-iaq f+s 7"AtF AD Jw t:r-ruT lyE/G1I12zkS U9" RKl l S AM k 1 eAJg-fA So Reason for requesting development: Fbp- s E 4! A&ruyg-L Tv <Iv s rA-6L 7- 1�� 1s ACKO WLEDGEMENT I hereby declare,to a best of kno e and belief,the forgoing information and all attached information is true and correct. (applicant or au orized representative) (date) I:\PLANNINGICHARELL&RENEEJSHORELINEPERMIT.APP REVISED: 01-05-2005 Publication cost is the responsibility of the applicant. Final permit processing will not occur until advertising fees have been paid to the newspaper by the applicant. The Shelton-Mason County Journal will bill the applicant directly. I /WE understand that I /WE must sign and date the attached acknowledgment indicating and that I / WE understand that is MY/ OUR responsibility. I /WE must submit the signed page as part of application in order for it to be considered as complete. DATE: /?oty_* OWNER A�_ APIkICANT Special Use Permit: $1,135.00 plus Hearings Examiner: $2005 or $670 for ADU's Applicant will also be billed for all advertising costs.Acceptance of this application,by Mason County does not guarantee approval. I TLANNINGTACTORMS Updated 12/15/08