Revised 11-30-2011
SWINOMISH INDIAN TRIBAL COMMUNITY
OFFICE OF PLANNING & COMMUNITY DEVELOPMENT
11430 Moorage Way ● La Conner, WA 98257
Phone 360-466-7280 • Fax 360-466-1615
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
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:
Project Description (attach additional documentation as necessary):
Estimated quantity of excavation/fill: (cubic yards)
Application 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
click to sign
signature
click to edit
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