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: __________________________
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