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Page 1 of 2 Office Use Only ACCEPTED Related 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] Shin Goto Digitally signed by Shin Goto DN: cn=Shin Goto, o=S+L Architects, LLC, ou, email=[EMAIL REDACTED], c=US Date: 2016.01.12 10:10:20 -08'00' [PHONE REDACTED] 2731 183rd Ave S.E. Snohomish, Wa 98290 Shin Goto [EMAIL REDACTED] [EMAIL REDACTED] [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] 98290 WA 98007 WA Snohomish Bellevue 2731 183rd Ave S.E. 2731 183rd Ave S.E. Snohomish, Wa 98290 S+L Arachitects, LLC Bellevue Children's Academy Shin Goto Ms. Yuka Shimizu Not Applicable Not Applicable R-1, R-4 15.2 262605910005, 262605907100, 262605901905, 262605901996, 262605905005, 262605905203 12280 Redmond-Woodinville Road Redmond WA 98052 Willows Preparatory School Conditional Use Permit & Site Entitlement ATTACHMENT 22 ---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: ADDITIONAL PROJECT INFORMATION Wetlands Delineation Report, Critical Areas Report, Geo-technical Report Construction permit from Redmond. none known (Phase II ) Building new 200 student classroom. (Phase III) Building new student dormitory. (Phase IV). Building new 200 student classroom. The following phases will be constructed as funds become available: and be operational with 300 students by Sept. 2017. (Phase I) The owner anticipates to move into the new classroom Building Willows Preparatory School Master Panned Development ATTACHMENT 22