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DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT
L
Planning Division
1055 South Grady Way, 6th Floor I Renton, WA 980571425-430-7200
www.rentonwa.gov
LAND USE PERMIT MASTER APPLICATION
PROPERTY OWNER(S)
NAME: Jeremy Jacobson
ADDRESS: 5117 NE 25th St
CITY: Renton ZIP: 98059
TELEPHONE NUMBER: (206) 390-6715
APPLICANT (if other than owner)
NAME: SOOS Creel( Water & Sewer District
COMPANY (if applicable): n/a
ADDRESS: 14616 SE 192nd St
CITY: Renton ZIP: WA
TELEPHONE NUMBER: (253) 630-9900
CONTACT PERSON
NAME: Brian Wilson
COMPANY (if applicable): Stantec
ADDRESS: 11130 NE 33rd PI #200
CITY: Bellevue ZIP: 98004
TELEPHONE NUMBER AND EMAIL ADDRESS:
(425) 533-5204
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1
PROJECT INFORMATION
PROJECT OR DEVELOPMENT NAME:
Cascade Hills, Phase 3 AC Pipe Replacement
PROJECT/ADDRESS(S)/LOCATION AND ZIP CODE:
11818 SE 165th ST
Renton, WA 98058
KING COUNTY ASSESSOR'S ACCOUNT NUMBER(S):
1423800180
EXISTING LAND USE(S):
Single Family(Res Use/Zone)
PROPOSED LAND USE(S):
n/a
EXISTING COMPREHENSIVE PLAN MAP DESIGNATION:
n/a
PROPOSED COMPREHENSIVE PLAN MAP DESIGNATION
(if applicable)
n/a
EXISTING ZONING:
Single Family(Res Use/Zone)
PROPOSED ZONING (if applicable):
n/a
SITE AREA (in square feet):
7,738
SQUARE FOOTAGE OF PUBLIC ROADWAYS TO BE
DEDICATED:
n/a
SQUARE FOOTAGE OF PRIVATE ACCESS EASEMENTS:
n/a
PROPOSED RESIDENTIAL DENSITY IN UNITS PER NET
ACRE (if applicable)
n/a
NUMBER OF PROPOSED LOTS (if applicable)
n/a
NUMBER OF NEW DWELLING UNIT§;,,0:applicabl�):
n/a
H:\CED\Data\Forms-Templates\Self-Help Handouts\Planning\Master Application.doc Rev: 10/2017
PROJECT INFORMAT
NUMBER OF EXISTING DWELLING UNITS (if applicable):
n/a
SQUARE FOOTAGE OF PROPOSED RESIDENTIAL
BUILDINGS (if applicable): n/a
SQUARE FOOTAGE OF EXISTING RESIDENTIAL
BUILDINGS TO REMAIN (if applicable): n/a
SQUARE FOOTAGE OF PROPOSED NON-RESIDENTIAL
BUILDINGS (if applicable): n/a
SQUARE FOOTAGE OF EXISTING NON-RESIDENTIAL
BUILDINGS TO REMAIN (if applicable): n/a
NET FLOOR AREA ON NON-RESIDENTIAL BUILDINGS (if
applicable): n/a
NUMBER OF EMPLOYEES TO BE EMPLOYED BY THE NEW
PROJECT (if applicable): n/a
ION continued
PROJECT VALUE:
$5,000
IS THE SITE LOCATED IN ANY TYPE OF
ENVIRONMENTALLY CRITICAL AREA, PLEASE INCLUDE
SQUARE FOOTAGE (if applicable):
❑ AQUIFER PROTECTION AREA ONE
❑ AQUIFER PROTECTION AREA TWO
❑ FLOOD HAZARD AREA
sq. ft.
❑ GEOLOGIC HAZARD
sq. ft.
❑ HABITAT CONSERVATION
sq. ft.
Q SHORELINE STREAMS & LAKES
sq. ft.
❑ WETLANDS
sq. ft.
LEGAL DESCRIPTION OF PROPERTY
on separate sheet with the following information included
SITUATE IN THE NW QUARTER OF SECTION 28 , TOWNSHIP 23 , RANGE 05 , IN THE CITY
OF RENTON, KING COUNTY, WASHINGTON
AFFIDAVIT OF OWNERSHIP
I, (Print Name/s) , declare under penalty of perjury and laws of the State of
Washington that I am (please check one) the current owner of the property involved in this application or" the authorized
representative to act for a corporation (please attach proof of authorization) and that the foregoing statements and answers herein
contained and the information herewith are in all respects true and correct to the best of my knowledge and belief.
nature�er'Ripresentative Date
STATE OF WASHINGTON )
) SS
COUNTY OF KING )
Signature of Owner/Representative Date
I certify that I know or have satisfactory evidence that _ [z_(4t f f C_ lC c, } (T signed this instrument and
acknowledge it to be his/her/their free and voluntary act for the tis nd purpose mentioned in the instrument.
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oa�t ' `
LAM N TRAIN
NOTARY PUBLIC
STATE OF WASHINGTON
My Cw nlssim Expirm January 26, 2022
Notary Public in and for the State of Wa—shington
L I
Notary (Print):
My appointment expires: (]
H:\CED\Data\Forms-Templates\Self-Help Handouts\Planning\Master Application.doc Rev: 10/2017