O:\PLANNING\FORMS AND BROCHURES\ENGINEERING PERMIT APPLICATION 2017.DOC page 7
Other
Anticipated Start Date: ______________________ Anticipated Completion Date: ______________
A Department of Ecology Construction Stormwater Permit is required for projects that disturb ≥1 acre. Will your
project disturb ≥1 acre of land through clearing, excavating, or stockpiling of fill? Yes No
If yes, complete NOI at http://www.ecy.wa.gov/programs/wq/stormwater/construction/enoi.html
A Forest Practice Permit is required for all projects removing and selling timber from the property site. Will your
project remove and sell timber? Yes No
A BNSF Permit is required for all projects that will discharge stormwater onto BNSF property (ROW). Does your
project discharge to BNSF ROW? Yes No
A Hydraulic Permit from the Department of Fish and Wildlife and / or from the Army Corps of Engineers is required for
all fill, or work within, over, or under a stream or wetland. Will your project involve stream or wetland?
Yes No
The list above is meant to provide guidance; it is the project applicant’s responsibility to identify and obtain all required
permits. All State, Federal, and/ or other applicable Permits shall be obtained and a copy provided to the City of
Mukilteo prior to issuance of the City of Mukilteo Engineering Permit.
The permittee shall indemnify, defend and hold harmless the City, its officers, agents and employees, from and
against any and all claims, losses or liability, including attorney’s fees, arising from injury or death to persons or
damage to property occasioned by the construction, installation, operation, location, maintenance, or any other cause
related to the improvement for which this permit is granted. With respect to this permit and as to claims against the
City, its officers, agents and employees, the permittee expressly waives its immunity under Title 51 of the Revised
Code of Washington, the Industrial Insurance Act, for injuries to any employees the permittee may have, and agrees
that the obligation to indemnify, defend and hold harmless provided for in this paragraph extend to any claim brought
by or on behalf of any employee of the permittee. This waiver has been mutually negotiated by the parties as part of
the permitting process and is given, as is the indemnification agreement contained within this paragraph, as
consideration for issuance of a right-of-way use permit by the City. This paragraph shall not apply to any damage or
injury resulting from the sole negligence of the City, its agents or employees. To the extent any of the damages or
injuries referenced by this paragraph were caused by or resulted from the concurrent negligence of the City, its
agents or employees, this obligation to indemnify, defend and hold harmless is valid and enforceable only to the
extent of the negligence of the permittee, its officers, agents or employees, if any.
The acceptance of the conditions upon which this permit is granted shall be evidenced by the beginning of the
installation of said FACILITIES as set forth herein.
SEE ATTACHED INSURANCE REQUIREMENTS AND ACKNOWLEDMENTS. ADDITONAL SIGNATURE REQUIRED
.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PERMIT APPLICATION IN ITS ENTIRETY AND KNOW
THE SAME TO BE TRUE AND CORRECT. I AGREE TO COMPLY WITH ALL CONDITIONS, CITY ORDINANCES
AND STATE / FEDERAL LAWS REGULATING ACTIVITIES COVERED BY THIS PERMIT APPLICATION. I ALSO
ACKNOWLEDGE THAT IT IS MY RESPONSIBILITY TO MAINTAIN PUBLIC STREETS FREE OF DIRT AND
DEBRIS.
_____________________________________________________ _______________________________________________________
Property Owner Signature Date
_____________________________________________________ _______________________________________________________
Applicant Signature Date
(if different than property owner)
Digitally signed by Jeff Mallahan
Date: 2020.08.14 16:19:06 -07'00'
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