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DEPARTMENT OF <br />ECOLOGY <br />State of Washlogton <br />NOTICE OF INTENT (NO[) <br />APPLICATION FORM <br />Construction Stormwater <br />General Permit <br />Check if applicable: <br />❑ Change or Update Permit Information <br />❑ Modification of Permit Coverage <br />Permit #WAR <br />Please print or itype all sections of this application. All fields are required unless otherwise marked. <br />1. Operator/Permittee (Party with operational control over plans and specifications; or day-to-day operational <br />control of activities which ensure compliance with SWPPP and permit conditions. Ecology will send <br />correspondence and permit fee invoices to the permit holder on record.) _ <br />Name: James Axthelm <br />Company: Axthelm Construction <br />Business Phone: 360.424.6848 Ext. <br />Unified Business Identifier (UBI): 601926138 <br />Cell Phone (Optional): 360.661.4949 <br />(UBI is a nine -digit number used to identify a <br />Fax (Optional): 360.428.0206 <br />business entity. Write "none" if you do not have a <br />E-mail:a rilaxtiuelm@councastnet <br />UBI number.) <br />Mailing Address: <br />City: <br />State: <br />Zip + 4: <br />1 <br />PO Box 2947 <br />Mount Vernon <br />I 1 <br />98273 <br />II. On -site Contact Person (Typically the Certified Erosion & Sediment Control Lead or Operator/Permittee) <br />Name: James Axthehn <br />Company: Axthelm Construction <br />Business Phone: 360.424.6848 Ext. <br />Mailing Address: <br />Cell Phone (Optional): 360.661.4949 <br />PO Box 2947 <br />City: <br />State: <br />Zip + 4: <br />Fax (Optional): 360.428.0206 <br />E-mail:aprilax!hclm@comcasL.net <br />MounLVernon <br />WA <br />98273 <br />III. Site Information _ <br />Site or Project Name <br />Site Acreage <br />Bob's Burger and Brew <br />Total size of your site/project (that vou owrulconlrol): <br />1.26acres. <br />Street Address or Location Description (If the <br />site lacks a street address, list its specific location. <br />For example, Intersection of Highway 61 and 34.) <br />Total area of soil disturbance (grading and/or <br />excavating) for your site/project over the life of the <br />16 05 Southeast Everlt Mall Wt� Everett WA 90208 <br />project: 1 26acres. (Note: 1 acre = 43,560 it.) <br />Parcel IDM 28051000405700 (Optional) <br />Concrete I Engineered Soils <br />How many yards of concrete will be poured? 350yd3 <br />Type of Construction Activity (check all that apply): <br />(estimate) <br />❑ Residential <br />® Commercial <br />How many yards of recycled concrete will be used? <br />❑ Industrial <br />t)yd' estimate <br />❑ Highway or Road (city ,county, state) <br />❑ Utilities (specify): — <br />Will any engineered soils be used? (For example: <br />❑ Other (specify):_ <br />cement treated base, cement kiln dust, etc.) <br />❑ Yes 0 No <br />Estimated project start-up date (mm/dd/yy): 02/01/10 <br />City (or nearest city): Ev rett <br />Zip Code: <br />Estimated project completion date (mm/dd/yy): <br />County: Snohomish <br />98208 <br />08/01/10 <br />— <br />Record the latitude and longitude of the main entrance to the site or the approximate center of site. <br />Degrees Minutes Seconds Degrees Minutes Seconds <br />Latitude:470 54' 51"N Longitude:122° 12' 45"W j <br />For assistance with latitude and longitude, refer to any of the following websites: www.getiation.com or <br />htip:lAvww.epz.govlirilreportlsiting_toollindex.htm. Please convert all latitude and longitude coordinates into <br />degrees, minutes, seconds format. For help with this process, go to: http.lAvww.fcc.govlmblaudiolbickel/DDDMMSS- <br />decimal.html. <br />NO <br />