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5. CONTACT PERSON <br /> Select one person the city will contact for anything Applicant 1[ Property Owner ❑ Contractor <br /> related to this project: <br /> r i Other(list helnwl <br /> Name: Phone: <br /> Lance— C"if t// 3% 0 — (. C% 4 <br /> Address(Street,City,State,Zip): Email Address: <br /> LP V r 0 v-t z d G, .h /.=14/ %. c-4 <br /> 7. ACKNOWLEDGEMENTS & SIGNATURE <br /> Read and initial each of the following statements prior to signing this application: <br /> I understand that when a clearing and grading permit application is taken in over the counter it <br /> does not mean the application has been deemed technically complete and sufficient for staff <br /> review. <br /> tz I understand that if I submit incomplete, inaccurate,and/or erroneous information it will take the <br /> City longer to process my permits. <br /> I understand and acknowledge that I could be responsible for providing as-built drawings(on paper <br /> or electronically) as part of the project's final approval process. <br /> I understand and acknowledge that Special Inspections could be required as part of my project, and <br /> if needed I will be required to pay for the cost of these inspections. <br /> I understand and acknowledge that financial securities could be required as part of the work I am <br /> L-' completing and I agree to provide the items needed for the City to calculate these securities and to <br /> provide the securities themselves. <br /> I understand that if permits are reviewed concurrently such as SEPA,critical areas, or shoreline <br /> ✓ permits,any required revisions to one permit may affect the entire plan set and could add costs <br /> and time to the project. <br /> I hereby declare that I am either the owner of the property listed on this application or the owner of <br /> this property has authorized me to be their representative to act for them. I also declare under <br /> penalty of perjury under the laws of the State of Washington that all of the statements and answers <br /> contained herein, and the information submitted with this application form is in all respects,true, <br /> correct, and complete to the best of knowledge and belief. <br /> Cev�eif /J � /S � 2_; <br /> S ature Date <br /> L ],-7-7, 47 11 <br /> Printed Name <br /> City Of Anacortes Clearing&Grading Permit Application <br /> Updated March 12,2021 Page 2 of 14 <br />