HomeMy WebLinkAboutL_Cornwall_JARPA Attachment E_Signed_181018_v1.pdfl ly
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AGENC'YUSEONLY ;
Date received: Us Army corps
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at Engineers • I
snatlle Application Fee Received; ❑ Fee N/A ;
Joint Aquatic Resources Permit ❑ New Application; ❑ Renewal Application
Application (JARPA) of eAi Type/Prefix #: ; NaturE Use Code:
LM Initials & BP#:
RE Assets finance BP#:
Attachment E: i NewApplication Number:
Trust(s): ;County
Aquatic Use Authorization on
`7 AQR Plate #(s):
Department of Natural Resources Gov Lot#(s):
(DNR) -managed aquatic lands Lg_!pj Tax Parcel#(s):
----=- --- ----- - -- ---- -------------- -- - -
Complete this attachment and submit it with the completed JARPA form onlly if you are applying for an Aquatic
Use Authorization with DNR. Call (360) 902-1100 or visit http:Lwww_dnr.wa.gov/programs-and-
services a uatics leasin -and-land-transactions for more information.
• DNR recommends you discuss your proposal with a DNR land manager before applying for
regulatory permits. Contact your regional land manager for more information on potential permit and
survey requirements, You can find your regional land manager by calling (360) 902-1100 or going to
httpalwww.dnr.wa.gov/programs-and-services/aguatics/aquatic-districts-and-land-managers-map.
ItLpl
• The applicant may not begin work on DNR -managed aquatic lands until DNR grants an Aquatic Use
Authorization.
• Include a $25 non-refundable application processing fee, payable to the "Washington Department of
Natural Resources." (Contact your Land Manager to determine if and when you are required to pay this
fee.) h[ e p]
DNR may reject the application at any time prior to issuing the applicant an Aquatic Use Authorization.h� el
Use black er blue ink to enter answers in white spaces below.
1. Applicant Name (Last, First, Middle)
Cornwall, Gerald
2. Project Name (A name for your project that you create. Examples: Smith's Clock or Seabrook Lane Development) [help]
Cornwall Boat Lift
I Phone Number and Email
206-856-3325
4. Which of the following applies to Applicant? Check one and, if applicable, attach the written authority— bylaws, power of
attorney, etc hel
C Corporation
❑ Limited Partnership
❑ General Partnership
❑ Limited Liability Company
Home State of Registration:
® Individual
❑ Marital Community (Identify spouse):
❑ Government Agency
❑ Other (Please Explain):
JARPA Attachment E Rev_ 1012016 Page 1 of 2
5. Washington UBI (Unified Business Identifier) number, if applicable: ipi
6. Are you aware of any existing or previously expired Aquatic Use Authorizations at the project location?
Z Yes ❑ No ❑ Don't know
If Yes, Authorization number(s): 22-086046
7. Do you intend to sublease the property to someone else?
❑ Yes ® No
If Yes, contact your Land Manager to discuss subleasing.
8. If fill material was used previously on DNR-managed aquatic lands, describe below the type of fill material
and the purpose for;using it. hel
To be com leted b .NR;and a" co retur.ndd.to.tf e a licant,.
Signature for projects on DNR -managed aquatic lands:
Applicant must obtain the signature of DNR Aquatics District Manager OR Assistant Division Manager if the
project is located on DNR -managed aquatic lands.
I, a designated representative of the Dept. of Natural Resources, am aware that the project is being proposed on
Dept. of Natural Resources -managed aquatic lands and agree that the applicant or his/her representative may
pursue the necessary regulatory permits. My signature does not authorize the use of DNR -managed aquatic
lands for this project.
Printed Name
Dept. of Natural Resources
Dis#44-Mefrager-apAssistant Division Manager
Signature
Dept. of Natural Resources
Diet�iet-AAanager or Assistant Division Manager
9/ 30�( s
Date
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 ORIA-16-016 rev. 1012016
JARPA Attachment E Rev. 1012016 Page 2 of 2