Loading...
HomeMy WebLinkAboutSHR2022-00006 BLD2022-00606 Pier JARPA - SHR Application - 5/16/2022 c � Zozz--00tv0(0 RECEIVED: MASON COUNTY RECEIVED I` COMMUNITY SERVICES MAY 16 2022 �. Building,Planning,Environmental Health,Community Health i/ 615 W.Alder St.-Bldg.8,Shelton,Wa 98584 615 W. Alder Street Phone:(360)427-9670 ext.352 ♦ Fax:(360)427-7798 PERMIT NO.:_)I� -ZA22'tY�arl p SHORELINE PERMIT APPLICATION SHORELINE PERMITS CONDITIONAL USE* SUBSTANTIAL DEVELOPMENT VARIANCE* ❑ EXEMPTION ❑ ACCESSORY DWELLING UNIT* 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 $7,047.00 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 may further describe the proposed development. Incomplete applications will be returned. *Shoreline Variances and Conditional uses require public hearings and have additional pages that shall be attached to this application. APPLICANT: Qn n-c 4 r, I�/��f/P� ADDRESS: 11 SO I NE I oZ rl d C� ne I ry,0-V(il 1 (street) w A �o�2 (city)` (/l (state) (zip) TELEPHONE: (home) }� n (business) AUTHORIZED REPRESENTATIVE: 1,6arrl ADDRESS: crb,4 N F, y4ay-e4+e- V A,0 (strell) (city) (state) (zip) TELEPHONE: PROPERTY DESCRIPTION: General location (include property address,water body and associated wetlands—identify the name of the shoreline): �l5 g o E M a o n I,al,/-ie [�r \A). o n (,�t(�>°) h o w e rl 5 Rev. Nov. 30, 2021 r Include all parcel numbers: Projects located in open water areas, away from land shall provide latitude/longitude. Z22'�3-5 ( -00025 OWNERSHIP: Contract Applicant Owner Lessee Purchaser (Identify) Other Owner: (street) (city) (state) (zip) DEVELOPMENT DESCRIPTON: Development proposal (identify and describe the proposed project, including the type of materials to be used, construction methods, principle dimensions, and other pertinent information): Cvn, d)W uC uJ 33 -n� fo p k �e� � Z� - (-ee+ �vewva�L ��� (o .-aof iy r�- Cvo4 ),C-+. peep woo kauc _ A, 1'5 joo_� b y Zo- f + > -�nsir�►� , �-�� w� pl of V� r(-in -f-w�,(� Existing Use(identify curr4nt use of property with exist improvements): ���iiG�evr hGc I N6w hrM cm�MOhCYI Reason for requesting development: f�ecrt'a�� bQC�N , DWI I`t'1� r�� � Lea-(�v ��LGL(-GG� aG�'►v�-heS C4h(� YY100✓�� . Estimated Fair Market Value of Project to Closest$1,000: "'C 101 ,0w a ' The Applicant shall provide, at a minimum, the following information: a. SITE PLAN -drawn to scale and including: i. The boundary of the parcel(s)of land upon which the development is proposed; ii. The ordinary high water mark (OHWM). This may be an approximate location provided, that for any development where a determination of consistency with the applicable regulations requires a precise location of the OHWM the mark shall be located precisely and the biological and hydrological basis for the location as indicated on the plans shall be included in the development plan.Where the OHWM is neither adjacent to or within the boundary of the project, the plan shall indicate the distance and direction to the nearest OHWM of a shoreline; iii. Where appropriate, the proposed land contours using five-foot intervals in water area and ten-foot intervals on areas landward of OHWM, if development involves grading, cutting,filling, or other alteration of land contours; iv. The dimensions and location of existing structures which will be maintained; v. The dimensions and locations of proposed structures; parking and landscaping; vi. The location of proposed utilities, such as sewer, septic tanks and drain fields, water, gas and electricity; vii.The location, source, composition, and volume of fill material; viii. The location, composition and volume of any extracted materials, and proposed disposal area; b. CROSS SECTION, drawn to scale including: i. The existing ground elevations; ii. The proposed ground elevations; iii. The location and height of existing structures; iv. The location and height of proposed structures; V. The OHWM. c. VICINITY MAP, including: i. The location of subject parcel using natural points of reference(roads, state highways, prominent landmarks, etc.). ii. If the development involves the removal of any soils by dredging or otherwise, identify the proposed disposal site on the map. If disposal site is beyond the confines of the vicinity map, provide another vicinity map showing the precise location of the disposal site and its distance to nearest city or town. iii. On the map, or separately, give a brief narrative description of the vicinity of the proposed project including identification of the adjacent uses, structures and improvements, intensity of development and physical characteristics. d. ADJACENT LANDOWNERS. Provide names and mailing addresses of all real property owners within 300 feet of property line boundaries where development is proposed as mailing labels or pre-addressed envelopes. ACKOWLEDGEMENT: I hereby declare, to the best of my knowledge and belief,the forgoing information and all attached information is true and correct. (Applicant or Authorized Representative) (date) AFFIDAVIT OF POSTING NOTICE STATE OF WASHINGTON ) ) ss: COUNTY OF MASON J RE: (Parcel#or Address of Site): 4 S90 E M45arl LoiI1e. OC. G rqp e✓.eti, (Va 33.5I-po p Z5 I, Julie Lewis , Planner for Mason County, do hereby certify that I have posted 1 copies of the attached: Notice of Application d On this �h day of No✓e,r1 L`w , 20 2a , in conspicuous places as follows: o One at o One at The Mason County Building One's Public Bulletin Board [411 N 5"St-Shelton,WAI o One at hd In, Jwitness whereof, the party has signed this Affidavit of Posting Notice this a day of No v2W&t: , 20a2 Signed by Julie Lewis Mason County Community Services Department 615 W. Alder St-Shelton, WA 98584 Subscribed and sworn before me this 2h0 day of N WeA1-AbtoQ, , 20 22 1 certify that -� �- 'b signed this document. Notary Pub& FAAJRLkNE te of Washington NOTARY PUBLIC in and for the State of Washington, M PAYSSE MMISSION EXPIRES Printed Name of Notary: 66p nf- ?AySSE 12/29I2025 residing at: MASM COIAn. My Commission Expires: 12,12,112TUR (Notary Seal) ` r---------1 \EG V ---------' WAS H I N GTO N STATE US ng y Corps Date received: IMv, Se Engineers• MAY 16 2022 Seattle District I I Joint Aquatic Resources Permit � AgencyT*S1W#AicPr 3trPat Application (JARPA) Form' 2 I 1 USE BLACK OR BLUE INK TO ENTER ANSWERS IN THE WHITE SPACES BELOW. i Tax Parcel#(s): Part 1—Project Identification --------------------------------------' 1. Project Name (A name for your project that you create. Examples: Smith's Dock or Seabrook Lane Development) Sager Pier Part 2—Applicant 2a. Name (Last, First, Middle) Sager, Michelle Annette 2b. Organization (If applicable) 2c. Mailing Address (Street or Po Box) 17801 NE 102Dd Ct 2d. City, State, Zip Redmond, WA 98052 2e. Phone(1) A Phone(2) 2g• 2h. E-mail Fax 425-495-2514 annette_sager@hotmail.com Part 3—Authorized Agent or Contact 3a. Name (Last, First, Middle) McDonald, Leann Ebe 3b. Organization Shoreline Solutions LLC 3c. Mailing Address (Street or Po Box) 9784 NE Lafayette Avenue NE 3d. City, State, Zip Bainbridge Island, WA 98110 3e. Phone(1) 3f. Phone(2) 3g. Fax 3h. E-mail 206-300-2678 leannm@mac.com ORIA-16-011 Page 1 of 9 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. ® 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 Part 5—Project Location(s) ❑ There are multiple project locations. Complete the section below and use JARPA Attachment B 5a. Indicate the type of ownership of the property. (Check all that apply.) ❑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.) 4590 E. Mason Lake Drive West 5c. City, State, Zip(If the project is not in a city or town, provide the name of the nearest city or town.) Grapeview, WA 98546 5d. County Mason 5e. Provide the section, township, and range for the project location. 1/4 Section Section Township Range 33 22N 2W 5f. Provide the latitude and longitude of the project location. Example:47.03922 N lat./-122.89142 W long. ORIA-16-011 Page 2 of 9 47.351931 N, -122.941019 W 5g. List the tax parcel number(s) for the project location. 22233-51-00025 51h. Contact information for all adjoining property owners. (if you need more space, use JARPA Attachment Q.) Name Mailing Address Tax Parcel # (if known) SW: Sager, Michelle Annette 17801 NE 102"d Ct 222335100024 ..................................................................................................................................................__.........................................................................._..... Redmond, WA 98052 NE: Cavagnaro, David & Lesley 4600 E. Mason Lake Dr. W. 222335100027 ............................................... ................................................................................................._.._................................................................................. Grapeview, WA 98546 5i. List all wetlands on or adjacent to the project location. No wetlands 5j. List all waterbodies (other than wetlands) on or adjacent to the project location. Mason Lake 5k. Is any part of the project area within a 100-year floodplain? ❑ Yes ❑x No ❑ Don't know 51. Briefly describe the vegetation and habitat conditions on the property. Deciduous and evergreen trees, shrubs, and bushes. 5m. Describe how the property is currently used Recreational. New home under construction. 5n. Describe how the adjacent properties are currently used Residential to the north. Undeveloped to the south. 5o. Describe the structures (above and below ground) on the property, their purpose(s) and current condition. 3 storey home— new construction 5p. Provide driving directions from the closest highway to the project location, and attach a map. Directions from post office in Shelton: Head west on M E Reed Way to N 3rd St and turn right onto N 3rd St. Turn right onto W Pine St. and road name changes to E. Pine St. Keep straight onto WA-3/E Pine St. for 11.3 miles. Turn left onto E Mason Lake Rd. and bear left onto E Mason Lake Dr W. 4590 is on the right but is unmarked. Road sign markers read 4600, 4690, 4730, 4750 and 7800. Part 6-Project Description 6a. Briefly summarize the overall project. You can provide more detail in 6b. Construct new pier for boating and water related activities. Include RGC solar powered boat lift. 6b. Describe the purpose of the project and why you want or need to perform it. ORIA-16-011 Page 3 of 9 The purpose is to provide boating recreational enjoyment, while protecting the environment as much as possible. 6c. Indicate the project category. (check all that apply) ❑ Commercial N Residential ❑ Institutional ❑ Transportation N 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 N Boat Lift N 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 ❑ Other: 6e. Describe how you plan to construct each project element checked in 6d. Include specific construction methods and equipment to be used. • Identify where each element will occur in relation to the nearest waterbody. Indicate which activities are within the 100-year floodplain. Construct new 33-foot long pier (28-feet overwater) including 6-foot by 18-foot pier and a 15-foot by 20-foot extension supported by twelve steel piling. Install a RGC solar powered boat lift. 6f. What are the anticipated start and end dates for project construction? (Month/Year) • 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: September 2022 End Date: 2 days ❑ See JARPA Attachment D 6g. Fair market value of the project, including materials, labor, machine rentals, etc. $19,000 6h. Will any portion of the project receive federal funding? If yes, list each agency providing funds. ❑ Yes N 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 none,skip to Part 8.) 7a. Describe how the project has been designed to avoid and minimize adverse impacts to wetlands. N Not applicable 7b. Will the project impact wetlands? ORIA-16-011 Page 4 of 9 ❑ Yes C No ❑ Don't know 7c. Will the project impact wetland buffers? ❑ Yes ® No ❑ Don't know 7d. Has a wetland delineation report been prepared? 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? If Yes, submit the wetland rating forms and figures with the JARPA package. Yes ❑ No ❑ Don't know Not applicable 7f. Have you prepared a mitigation plan to compensate for any adverse impacts to wetlands? If Yes, submit the Ian with the JARPA package and answer 7 . 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. 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. Activity (fill, Wetland Wetland type Impact area Duratio Proposed Wetland drain, excavate, Name' and rating (sq. ft. or n of mitigation mitigation area flood, etc.) category' Acres) impact3 type' (sq. ft. or 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. 3 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/In-lieu fee B Page number(s)for similar information in the mitigation plan, if available: 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. 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. 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.) ❑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. ORIA-16-011 Page 5 of 9 0 Not applicable 50% grating on the 6-foot section of the pier. 30% on the attachment. 8b. Will your project impact a waterbody or the area around a waterbody? 0 Yes ❑ No 8c. Have you prepared a mitigation plan to compensate for the project's adverse impacts to non-wetland waterbodies? 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 0 No ❑ Don't know 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. The pier will have 50% grating for light penetration. 8e. Summarize impact(s) to each waterbody in the table below. Activity (clear, Waterbody Impact Duration Amount of material Area (sq. ft. or dredge, fill, pile name' location of impact3 (cubic yards) to be linear ft.) of drive, etc.) placed in or removed waterbody from waterbody directly affected 12 3" galvanized Mason Lake Waterbody 30 minutes No fill or excavation Less than 2.5 sf pipe supports 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. 2Indicate whether the impact will occur in or adjacent to the waterbody. If adjacent,provide the distance between the impact and the waterbody and indicate whether the impact will occur within the 100-year flood plain. 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. No fill other than piling. 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. Ko excavating or dredging. 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. 9a. If you have already worked with any government agencies on this project, list them below. Agency Name Contact Name Phone Most Recent Date of Contact Mason County 360-427-9670 WA State Dept Fish & Wildlife Noll Steinweg 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? 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/wg/303d/. ❑ Yes 0 No ORIA-16-011 Page 6 of 9 9c. What U.S. Geological Survey Hydrological Unit Code (HUC) is the project in? • Go to http://cfaub.epa.gov/surf/locate/index.cfm to help identify the HUC. 17110017 9d. What Water Resource Inventory Area Number (WRIA#) is the project in? • Go to http://www.ecy.wa.gov/water/wria/index.html to find the WRIA#. 14 9e. Will the in-water construction work comply with the State of Washington water quality standards for turbidity? • Go to htto://www.ecy.wa.gov/programs/wg/swgs/criteria.html for the standards. ® Yes ❑ No ❑ Not applicable 9f. If the project is within the jurisdiction of the Shoreline Management Act, what is the local shoreline environment designation? • For more information, go to: http://www.ecy.wa.gov/programs/sea/sma/laws rules/173-26/211 designations.html. ❑ Urban ❑ Natural ® Aquatic ❑ Conservancy ❑ Other: 9g. What is the Washington Department of Natural Resources Water Type? • Go to http://www.dnr.wa.gov/forest-practices-water-tvping 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? If No, provide the name of the manual your project is designed to meet. ❑x Yes ❑ No Name of manual: Current stormwater manual 9i. Does the project site have known contaminated sediment? If Yes, please describe below. ❑ Yes ❑ No 9j. If you know what the property was used for in the past, describe below. Undeveloped land. House construction to begin Spring 2021 9k. Has a cultural resource (archaeological) survey been performed on the project area? • If Yes, attach it to your JARPA package. ❑ Yes 0 No 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. Marbled Murrelet, Northern Spotted Owl 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. No affect by proposed work. Part 10—SEPA Compliance and Permits ORIA-16-011 Page 7 of 9 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 ccDoria.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.) • For more information about SEPA,go to www.ecy.wa.gov/programs/sea/sepa/e-review.html. ❑ A copy of the SEPA determination or letter of exemption is included with this application. ® A SEPA determination is pending with Mason County. The expected decision date is August 2022. ❑ 1 am applying for a Fish Habitat Enhancement Exemption. (Check the box below in 1 0b.) ❑ 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. 10b. Indicate the permits you are applying for. (Check all that apply.) LOCAL GOVERNMENT Local Government Shoreline permits: © Substantial Development ❑ Conditional Use ❑ Variance ❑ Shoreline Exemption Type (explain): Other City/County permits: ❑ Floodplain Development Permit ❑ Critical Areas Ordinance STATE GOVERNMENT Washington Department of Fish and Wildlife: ❑x Hydraulic Project Approval (HPA) ❑ Fish Habitat Enhancement Exemption —Attach Exemption Form ❑ 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 (Attach a copy of current land use classification recorded with the county auditor, or other proof of current land use) ❑ Project 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. Washington Department of Ecology: ❑ Section 401 Water Quality Certification FEDERAL GOVERNMENT ORIA-16-011 Page 8 of 9 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) Part 11-Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. 11 a. Applicant Signature (required) 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. MAS (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. HAS (initial) �''1� 4,t, c $fin. March 07, 2022 Michelle Annette Sager Applicant Printed Name Applicant Signature Date 11 b. Authorized Agent Signature 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. Leann Ebe McDonald March 07. 2022 Authorized Agent Printed Name Authorized Agent Signature Date 11 c. Property Owner Signature (if not applicant) 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. ORIA publication number: ORIA-16-011 rev.09/2016 ORIA-16-011 Page 9 of 9