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Page 1 of 2 NOTICE: This form must be completed (clearly printed or typed to a SEPA Checklist). Project Site Parcel Number(s): Shoreline APPLICANT/DEVELOPER INFORMATION APPLICANT OWNER Company Mailing Select Billing Contact: APPLICANT OWNER APPLICANT OWNER OTHER Company Mailing CONTACT INFORMATION (PRIMARY CONTACT REGARDING THIS APPLICATION IF OTHER THAN APPLICANT, AND TO WHOM ALL NOTICES AND REPORTS SHALL BE SENT.) AUTHORIZATION TO FILE SIGNATURE (ALL PERSONS WITH AN OWNERSHIP INTEREST IN PROPERTY) By my signature, I certify that the information and exhibits herewith submitted are true and correct to the best of my knowledge. Property Owner Individual authorized to sign on behalf of property owner Phone: SEPA Application Development Services Center, 15670 NE 85th St, Redmond, WA 98052 I [PHONE REDACTED] Name of Planner: Planner OFFICE USE ONLY: REVIEW PLANNER HAS REVIEWED CAO AND VERIFIED WAC/ RZC CITATIONS OR REQUIREMENT OF SEPA 10/18 SIGN SIGN ---PAGE BREAK--- Page 2 of 2 Development Services Center, 15670 NE 85th St, Redmond, WA 98052 I [PHONE REDACTED] Project name and description: Proposed timing or phasing and estimated completion date: Do you have any plans for future additions, expansions, or further activity related to or connected with this proposal? If yes, explain: Do you know of any plans by others that may affect this site? If yes, explain: List other federal, state, or local permits, licenses, or approval required for this proposal: List any environmental information that has been prepared or will be prepared regarding this proposal: SEPA VERIFICATION AND CAO WORKSHEET Based upon a review of the attached criteria: SEPA The proposal is exempt from requiring a SEPA Threshold Determination and therefore the SEPA filing fee does not apply. The applicable exemption is must note applicable WAC and RZC). The proposal is not exempt from requiring a SEPA Threshold Determination and therefore the SEPA filing fee applies. Critical Area Mitigation The proposal does not include activity that would require Critical Area mitigation, and therefore the CAO mitigation fee does not apply. The proposal includes activity that would require Critical Areas mitigation and therefore the CAO miti- gation fee applies. Note: The City makes the final determination as to whether CAO mitigation is required and whether a project is exempt from SEPA. Should the City make a determination that one or both fees apply, the applicable fee(s) ADDITIONAL PROJECT INFORMATION