I, THE UNDERSIGNED, SWEAR UNDER THE PENALTY OF PERJURY THAT THE ABOVE RESPONSES ARE MADE TRUTHFULLY AND TO THE
BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT, SHOULD THERE BE ANY WILLFUL MISREPRESENTATION OR WILLFUL LACK
OF FULL DISCLOSURE ON MY PART, THE AGENCY MAY WITHDRAW ANY DETERMINATION OF NON-SIGNIFICANCE THAT IT MIGHT
ISSUE IN RELIANCE UPON THIS CHECKLIST.
**BY LEAVING THE CONTRACTOR INFORMATION SECTION BLANK, I HEREBY CERTIFY FURTHER THAT CONTRACTORS (GENERAL OR
SUBCONTRACTORS) WILL NOT BE HIRED TO PERFORM ANY WORK IN ASSOCIATION WITH THIS PERMIT. (building permits only)
______________________________________________________
_____________________________________________ DATE: _____/_____/______
SIGNATURE OF OWNER / AUTHORIZED AGENT PRINTED NAME
City of Sumner
SEP
A
Application
(Please fill out ALL fields unless otherwise noted)
Sup
porting Materials Required:
Office Applicant - (please check off all “applicant” boxes)
SEPA Application Form and Checklist
4 copies of the completed SEPA Checklist
Required fee (Please consult the Permit Specialist)
Site Plan Drawing (To scale including ALL items below) 4 - 11” x 17”
(Prepared, stamped, and dated by a licensed surveyor) 2 - Full Sheet (24”x 36”)
o Legal Descriptions of existing and proposed lots
o Vicinity map and site zoning
o Property line dimensions and square footage of new lots
o Existing public and private roads, driveway access and all easements
o Existing and proposed fire hydrant locations or distance to the nearest hydrants
o All major man-made features; drainage ditches, railroad tracks, etc.
o Existing building locations and setbacks from property lines (if any)
o Proposed access width
o Building envelopes and lot number assigned to each lot
o Location of nearest existing utilities including sanitary sewer, storm drainage, and water services
o Environmental constraints identified and delineated (if any) such as wetlands, rivers, streams, slopes
Other information as applicable from Pre-Application review comments (Wetland reports, etc)
Mailing list of all property owners within 500 ft, 1000 if project is in M1 zone electronically (Excel)
PDF Copy of all submitted documents
Site/Project Address (if available): Parcel #:
Owner: Phone: Email:
Owner Address: City: State: Zip:
Surveyor/Engineer/Contractor: Phone: Contractor License Number:
Address: Email: City: State: Zip:
Contact Person: Phone: Fax:
Contact Address: Email: City: State: Zip:
Description of Project:
Community Development
1104 Maple Street, Suite 250
Sumner, WA 98390
Tel. (253)299-5530 Fax: (253)299-5539
www.ci.sumner.wa.us
File Number: __________________________
1510 Puyallup Street
042024-1124, 967500-0030, -0040, -0091, -0100, -0110
Duke Realty
(949) 797-7038
Adam.Schmid@dukerealty.com
200 Spectrum Center Drive, Suite 1600
Irvine
CA
92618
Barghausen Consulting Engineers, Inc.
(425) 251-6222
18215 72nd Avenue South
jhubbell@barghausen.com
Kent
WA
980932
Jason Hubbell, P.E., Senior Project Engineer
(425) 251-6222
(425) 251-8782
18215 72nd Avenue South
jhubbell@barghausen.com
Kent
WA
98032
Construction of an approximate 183,800 square foot warehouse type building, including storm
drainage facilities, landscaping, water and sewer utilities, dry utilities, truck docks and parking.
Jason Hubbell, P.E.
04
19
19
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