HomeMy WebLinkAboutSDP.SEPA Exemption.pdfComplete this form for the following:
• Activities defined as development pursuant to RCW 90.58.030; and
• Are located within the shoreline jurisdiction as defined by the Shoreline Management Act; and
• Are listed as exemptions in WAC 173-27-040(2)
Owner Name:
Property Address:
Legal Description:
Tax Parcel Number:
Lot Size:
Critical area(s) located on the property (Ch. 16.50 MMC)?
❑ YES ❑ NO
...
Contact Person:
Email:
Contact Phone:
Alternative Phone:
Mailing Address:
City: State: Zip:
Total cost of the project:
SEPA Exempt?
❑ YES ❑ NO (If no, submit an Environmental (SEPA) Checklist
Please provide a complete description of the proposed project, include which exemption criteria of WAC 173-27-040(2) pertains to
this project (attach additional pages if necessary).
1 of 2 Rev. 11/2021
Current use of the property:
Please list any other permits for this project from state, federal, or local governmental agencies for which you have or will apply:
I certify under the penalty of perjury that I am the owner of the above property or the duly authorized agent of
the owner(s) acting on behalf of the owner(s) and that all information furnished in support of this application
is true and correct.
Signature
Signature
Owner ❑ Agent ❑ Date
Owner ❑ Agent ❑ Date
2 of 2 Rev. 11/2021