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Be sure to also complete Section C(Signature Block)for all permit applications. 1.APPLICANT (i!Mf- Cby MAILING ADDRESS 3 " Iti1 ��- TcaCc�rr.a UJ A . 9 g4o$ WORK PHONE HOME PHONE FAX# Zs y7a-2-7-4 9 Kan agent Is acting for the applicant during the permit process,complete#Z 2.AUTHORIZED AGENT Z tikes Con s4-r o w4 MAILING ADDREP 3 ORKPHONE HOME PHONE FAX# Z^7s-Sva 3.RELATIONSHIP OF APPLICANT TO PROPERTY: OWNER ❑PURCHASER ❑LESSEE ❑OTHER: 4.NAME,ADDRESS,AND PHONE NUMBER OF PROPERTY OWNER(S),IF OTHER THAN APPLICANT. S.LOCATION(STREET ADDRESS,INCLUDING CITY,COUNTY AND ZIP CODE,WHERE PROPOSED ACTIVITY EXISTS OR WILL OCCUR) 2:721 rift �4 >' l7(. L. bra w-,e� WATER1309Y TRIBUTARY OF �n i!1--t 1/4 SECTION TOWNSHIP RANGE GOVERNMENT LOT SHORELINE DESIGNATION 32) ;Z-)- D- ZONING DESIGNATION TAX PARCEL NO.: DNR STREAM TYPE,IF KNOWN ZZ2 33 S2 I� Application Page 1 d 4 V 10 Z Q6rd u04"iddV ON� S3A❑ 6SONY113M-40 SNINWW a0°JNIOOOIj 3snvO ALALLOV 03sOdOad TvA Zl 38 NVO NOLLVWaOjN1 SIIOS 'S110S OIaOAH j 3a 0 isn sAiNflOO 3H1 NO V A3H1 A 31vOI0N1 '31IS3('Oad 3H11Va3SNOO S asj 3a� sa Lr - llY Im , :33anOS lVRI31VW'3 :('313'ONUS'J 3)lVIa31VW 1113 30 NOWSOdYM ONV 3d U O ON❑ S3A❑ NOLLV3nddV HllM 111048nS 3SV3ld'S3A jl 403aVd3ad N338 laOd3a ONYl13M V SVH'O ON❑ S3A❑ NOLLVOIIddV HllM 111048nS 3SV31d'S3A-Al LO313ldWOO N338 NOLIV3NIl30 V SVH a S3a3V NI V3NV 03L3VdWl'V S3A jl 00 S3A❑ 1SONTUM N1033VId 381V1831VW TIM'LL (S3a3V) d3aV/ (S(i21VA 3I8l13)3Wf1lOA'S3A jl LSa31VM IVOLL aOj 831VM HEM 83HOlH NV3104 314130 08VMa31VM❑ S3N3V) V3av/ (SOavA 318(13)Elvm- A'S3A jl [ LSa31VM HS3aj 803 3NII 80 NUM a31VM HJIH AaVN10a0 3H130 OaVMa31VM'$ '7U% O30Y1d 38(lVIa31VW a3H10 a0 sJMUd'OY3HNll18'lll3 1>mw lVIa31V W Tlj lIIM'01 Sa31VM IVOLL M 3Nn 831VM HJIH NV3W 3H1 j0 0aVN1a31VM❑ a0/ONV'Sa31VM IVOLL 80 HS3)jj HOj 3NIl aO NUM a31VM HJIH AaVN1Oa0 3H1 j0 OaVMa31VM(92 :O3OVld 38 llIM S3af11.OnHIS ANV jl N33HO'S 'Aa-,3-rn f AunLLMV jO NOLL"no 031vW11s3 :31V0 ONLLavls 03sodosd ON❑ S3A❑ lS30V1S N10313nHj.SNO3 39 L-aMad 3H1 TUM'8 a3N10 A9 03H/n03a 38 AYIY SJNIMYaO?I3'JaY7 "S133NS NON/1{X ZIA-8 NO SgNlMYao 3?1/n03t/p?/YnO1sy0O p/yy sa33NlEM1330 SdLpO 3/{L s Y r3:lr:w:Lsens lON 00 3S3H11118 3LS 133POad 3H1 j0 SHdVaJOIOHd BVIS S 0103J1 M)ON3 311V SINVOIIddV 31ON -03H0Y1LY3013�/f3Y SON/MYM037g/OnOOild3y A"wn0 OOOJ 80 7VN/J/a0-4013S 3N0 'SJNIMVW 31,11 f)NL13IdWOO aOj 1SII>03HO ONV SEJNIMVaO 3ldWVS-V XION3ddV 33S :SONIMVaO j0 N011VWYd3ad NOLL33108d 83dOad 3OIAOad ONV'S13VdW11V1N3WRt130 31VOWW(INV'MMINIW'OIOAV 01 SNOl1OV 03SOdOad AJUN301 'SOLL3HLS3V Put'NOLLV3aO3a'AlddnS a31vM'ALnvf1O a31vM'33113LLvnt)v ONv HSIj 30f113N1 Am S3sn 3S3H1 AOO8 a31VM 3H130 S3sn oLLSIa313vavH3 Ol s13vdWl WL1N310d 3H1381a3s3O '3L �oq pi n =,-- >IHOM 03SOdOad 3Hl j0 3SOdand 31-113818OS30'qL o �nou.,ia -�poC. -fib a0 HaVW H31VM HJIH AaVNIOHO 3H1 j0 OaVMa31VM NaOM TV WA 0301AOad 38 01flOHs sNOL1VOIj103dS ONV SNvld 3131dW00'AWM 03SOdOad 3H138 knO 'vL 7S3A6 L NVdYJLLavd WVaJOad vOsn v nOA 38V ON❑S3A❑LONY1 IY811onowov Ala3dOad 3H1 SI No o313ldwoo AOV3alY st ALALL7V a3sodoad 3H1 jo Nollaod ANv jt 'Auedoad 3H1 No`JNl1SD0 s3af1 onws oNv mad am j0 3sn L 43aallO 3FLL vsl'Y JIF YES,IMPACTED AREA IS _ACRES 13.WILL EXCAVATK)N OR DREDGING BE REQUIRED IN WATER OR WETLANDS? ❑YES IF YES: A.VOLUME:_(CUBIC YARDS)/AREA_(ACRES) B.COMPOSITION OF MATERIAL TO BE REMOVED. C.DISPOSAL SITE FOR EXCAVATED MATERIAL: D.METHOD OF DREDGING: 14,LIST OTHER APPLICATIONS,APPROVALS,OR CERTIFICATIONS FROM OTHER FEDERAL,STATE OR LOCAL AGENCIES FOR ANY STRUCTURES,CONSTRUCTION,DISCHARGES, OR OTHER ACTIVITIES DESCRIBED IN THE APPLICATION(I.E.,PRELIMINARY PLAT APPROVAL,HEALTH DISTRICT APPROVAL,BUILDING PERMIT,SEPA REVIEW,FERC LICENSE, FOREST PRACTICES APPLICATION,ETC.)ALSO INDICATE WHETHER WORK HAS BEEN COMPLETED AND INDICATE ALL EXISTING WORK ON DRAWINGS. TYPE OF APPROVAL ISSUING/AGENCY IDENTIFICATION NO. DATE OF APPLICATION DATE APPROVED COMPLETED? m l C'OV(1' SEPA LEAD AGENCY SEPA DECISION: SEPA DECISION DATE: 15. HAS ANY AGENCY DENIED APP VAL FOR THE ACTMTY DESCRIBED HEREIN OR FOR ANY ACTMTY DIRECTLY RELATED TO THE ACTMTY DESCRIBED HEREIN?ElYES�FO IF YES,EXPLAIN: SECTION B- Use for Shoreline and Corps of Engineers permits only: 16. TOTAL COST OF PROJECT, THIS MEANS THE FAIR MARKET VALUE OF THE PROJECT,INCLUDING MATERIALS,LABOR,MACHINE RENTALS,ETC_ 17. LOCAL GOVERNMENT WITH JURISDICTION: 18. FOR CORPS,COAST GUARD,AND DNR PERMITS,PROVIDE NAMES,ADDRESSES,AND TELEPHONE NUMBERS OF ADJOINING PROPERTY OWNERS,LESSEES,ETC.PLEASE NOTE: SHORELINE MANAGEMENT COMPLIANCE MAY REQUIRE ADDITIONAL NOTICE—CONSULT YOUR LOCAL GOVERNMENT. NAME ADDRESS PHONE NUMBER Application Page 3 of 4 SECTION C-This section MUST be completed for any pennit covered by this application. M 19. APPLICATION IS HEREBY MADE FOR A PERMIT OR PERMITS TO AUTHORIZE THE ACTIVITIES DESCRIBED HEREIN. I CERTIFY THAT I AM FAMILIAR WITH THE IWORMATION CONTAINED IN THIS APPLICATION,AND THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,SUCH INFORMATION IS TRUE,COMPLETE,AND ACCURATE I FURTHER CERTIFY THAT I POSSESS THE AUTHORITY TO UNDERTAKE THE PROPOSED ACTIVITIES. I HEREBY GRANT TO THE AGENCIES TO WHICH THIS APPLICATION IS MADE,THE RIGHT TO ENTER THE ABOVE-DESCRIBED LOCATION TO INSPECT THE PROPOSED,IN-PROGRESS OR COMPLETED WORK I AGREE TO START WORK ONLY AFTER ALL NECESSARY PERMITS HAVE BEEN RECEIVED. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT DATE I HEREBY DESIGNATE TO ACT A AGENT IN MATTERS RELA7ED TO THIS APPLICATION FOR PERMIT(S). I UNDERSTAND THAT IF A FEDERAL PERMIT IS ISSUED,I MUST SIGN THE PERMIT, SIGN OF APPLICANT DATE SIGNATURE OF LANDOWNER(EXCEPT PUBLIC ENTITY LANDOWNERS,E.G.DNR) DATE THIS APPLICATION MUST BE SIGNED BY THE APPLICANT AND THE AGENT,IF AN AUTHORIZED AGENT IS DESIGNATED. 18 U.S C§1001 prtr'J-s that t!c j.rzJ`--L; w—y iepamnent or agency or the United States Knowingly falsifies,conceals,or covers up by any trick,scheme,or device a material fad 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$10,000 or imprisoned not more than 5 years or both. 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' € ii4 YeaioacIaa� 5( year inn:.E3. 3sitatde :.. <:::::>:;::;;:;;.;:.;;;;;;;;;'.: .......:::.::.....:....:.... �:-:'°e!.ti»o�awryvot�.tV4„Nikh.�rlrAaaR Q�tS�Rit fkttnf}8f bat:Ltu3 titlC IS� tq$(t Lowesf bteid f:feval....... .......... feet,:: :-;:;:::.:::•;:->:.;:. . , arrd CciAstrttlOntrtantatro :;:::::::; ;;:.:;;::;:;::;;;• : IOft:...:,G(E.... ffs�,,..,,.. `. ?2:':? .:::... ..:..::..:.•.?"`r..:: ...... ................................... ......::.::::::>:::>:::.�:....... ...... ...: .......... .... '1 ..................... ...... i'!'i�E'ii is i?i!i2i;i?P�asisi;i '`r;!'>iiasisiiMas i::::::ii:isasi;i;i;isi::::::;:':asi' :iiEi > '.: `i ;:::� ''S 'i ..'i 5 tJCiT>: . r ''`' `''.'•, '`E'::'E:'."i`ES`£ .... :':................................................................E .'' `'%3'`?'': . :."?.S E%.%'< t 1 ` . ' '?':E3.% 'i..' .'. } '.` ..<; E E E E.E.' :.'.' E'E.E E E'E '.E .' %: . ` .%X. : :: These Agencies are Equal Opportunity and AflImis m Action employers. For speGal accorrrrnodeUon Reeds,please contact the approprlafe agency from Appendix B. Application Page 4 of 4 t