HomeMy WebLinkAboutDavis Shoreline Repair Master ApplicationPart 11—Authorizing Signatures
Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form,
project plans, photos, etc. [help]
11 a. Applicant Signature (required) [he�I t
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 autho,r�ize the agent named in Part 3 of this application to act on my behalf in matters related to this
application. �`1 (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. (initial)
Applicant Printed Name Applicant Signature Date
11 b. Authorized Agent Signature [heft
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.
Authorized Agent Printed Name Authorized Agent Signature Date
11 c. Property Owner Signature (if not applicant) [help]
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 for Regulatory Innovation and Assistance (ORIA) at (800)
917-0043. People with hearing lass can call 711 for Washington Relay Service. People with a speech disability can call (877) 833-6341.
ORIA publication number: ENV -019-09 rev. 0912015
JARPA Revision 2015.1 Page 14 of 14
DEPARTMENT OF COMMUNITYC9TY OF
AND ECONOMIC DEVELOPMENT------�------, �- Renton(D
Planning Division
LAND USE PERMIT MASTER APPLICATION
PROPERTY OWNER(S)
NAME: Paul & Deborah Davis
ADDRESS: 4211 Williams Ave N
CITY: Renton, WA ZIP: 98056
TELEPHONE NUMBER:
APPLICANT (if other than owner)
NAME:
COMPANY (if applicable):
ADDRESS:
CITY: ZIP:
TELEPHONE NUMBER:
CONTACT PERSON
NAME: Evan Wehr
COMPANY (if applicable): eCCo design inc.
ADDRESS: 203 N 36th St. Suite 201
CITY: Seattle, WA ZIP: 98103
TELEPHONE NUMBER AND EMAIL ADDRESS:
(206) 706-3937
PROJECT INFORMATION
PROJECT OR DEVELOPMENT NAME:
Davis Shoreline Repair
PROJECT/ADDRESS(S)/LOCATION AND ZIP CODE:
4211 Williams Ave N
Renton, WA 98056
KING COUNTY ASSESSOR'S ACCOUNT NUMBER(S):
0518500340
EXISTING LAND USE(S):
Single Family Residence
PROPOSED LAND USE(S):
NIA
EXISTING COMPREHENSIVE PLAN MAP DESIGNATION:
RHD
PROPOSED COMPREHENSIVE PLAN MAP DESIGNATION
(if applicable)
NIA
EXISTING ZONING:
R-10
PROPOSED ZONING (if applicable):
NIA
SITE AREA (in square feet):
5,581
SQUARE FOOTAGE OF PUBLIC ROADWAYS TO BE
DEDICATED:
NIA
SQUARE FOOTAGE OF PRIVATE ACCESS EASEMENTS:
NIA
PROPOSED RESIDENTIAL DENSITY IN UNITS PER NET
ACRE (if applicable)
NIA
NUMBER OF PROPOSED LOTS (if applicable)
NIA
NUMBER OF NEW DWELLING UNITS (if applicable):
NIA
H:\CED\Data\Forms-Templates\Seif-Help Handouts\Planning\Master Application.doc Rev: 08/2015
PROJECT INFORMA"
NUMBER OF EXISTING DWELLING UNITS (if applicable):
1
SQUARE FOOTAGE OF PROPOSED RESIDENTIAL
BUILDINGS (if applicable): NSA
SQUARE FOOTAGE OF EXISTING RESIDENTIAL
BUILDINGS TO REMAIN (if applicable): 3,790
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
PION continued
PROJECT VALUE:
0
$4,000
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IS THE SITE LOCATED IN ANY TYPE OF
ENVIRONMENTALLY CRITICAL AREA, PLEASE INCLUDE
SQUARE FOOTAGE (if applicable):
❑ AQUIFIER PROTECTION AREA ONE
❑ AQUI FIER PROTECTION AREA TWO
❑ FLOOD HAZARD AREA
sq. ft.
❑ GEOLOGIC HAZARD
sq. ft.
❑ HABITAT CONSERVATION
sq. ft.
LI SHORELINE STREAMS & LAKES 5,581
sq. ft.
❑ WETLANDS
sq. ft.
LEGAL DESCRIPTION OF PROPERTY
Attach legal descri tion on separate sheet with the following information included
SITUATE= IN THE NW QUARTER OF SECTION 32 , TOWNSHIP 24 N, RANGE 5 E , IN THE CITY
OF RENTON, KING COUNTY, WASHINGTON
AFFIDAVIT OF OWNERSHIP
1, (Print Name/s) Paul & Deborah Davis , declare under penalty of perjury under the laws of the State of
Washington that 1 am (please check one) ✓ the current owner of the property involved in this application or 0 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.
Signature of Owner/Representative Date Signature of Owner/Representative Date'
STATE OF aAlASEIW N }
) SS
COUNTY OF -KI )
I certify that I know or have satisfactory evidence that (q,/ / lb, 1)4* vt S a.ar bebol-cA ll I signed this instrument and
acknowledge it to be his/her/their free and voluntary act for the uses and purpose mentioned in the instrument.
% .2C's/';F
Dated
LAURA STOTTS
Commission #
2059171
0
Notary Public • California
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Riverside County
My Comm. Expires fear 26, 2018
Notary Public in and for the State o#-VVaehirrgton
Notary (Print):
My appointment expires: Ca"!{f' `<
H:\CED\Data\Forms-Templates\Self-Help Handouts\Planning\Master Application.doc Rev: 08/2015