Revised 11-30-2011
EXCAVATION & GRADING PERMIT APPLICATION PERMIT #__________
APPLICANT OWNER CONTRACTOR
Name: Name: Company:
Address: Address: Contact:
City: City: Address:
State: State: City: Zip Code:
Zip Code: Zip Code: Day Phone:
Day Phone: Day Phone: Cell Phone:
Cell Phone: Cell Phone: Fax:
Fax: Fax:
Registration No:
Expiration Date:
Designated agent/contact for application (check one only):
A
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licant Owner Contractor
PROJECTSITEIDENTIFICATION
Site Address: Lot/Block#: Parcel I.D. #
Plat Name/Short Plat #: Lot Size: acres/sq ft
PROJECTSITEINFORMATION
Purpose: Start Date: End Date:
Proje
ct Description (attach additional documentation as necessary):
Estimated quantity of excavation/fill: (cubic yards)
Applicati
on is hereby made for a permit to authorize activities described herein. I certify that I am familiar with the information
contained in this application and that to the best of my knowledge and belief such information is true, complete, and accurate. I
further certify that I possess the authority to undertake the proposed activities. I hereby grant to the officials of the Swinomish
Indian Tribal Community the right to enter the above-described location to inspect the proposed and/or completed work.
Signature (Required): _______________________________ Date: _______________
STAFFUSEONLY
Attached Supporting Documents:
Site Plan, with grading plan details showing existing and finished grades (3 copies)
Soils Report OR Exempt from Soils Report requirement
Liquefaction Study OR Exempt from Liquefaction Study
Date stamp
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signature
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