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16. Ha any agency deniad appmv�l for the activiry dacribed hmoin or for any utivity dinctly �elaiad to the scaviry <br /> described heroin? C Ya fr� No If yts, explain: <br /> SECT'ION B - Use for Shoreline & Cocpe of Enginxn permi�a only: <br /> 17. 'Cotal cos[ of Projecc. This means the faiz marlcet value of the psaject, inaluding mrttrials, Lbor, mtchine cwuls, etc. <br /> I8. Loca! govemment w/jurisdiction: <br /> Shoroline Fnvironmeut duigaation: Zoniag deai�ation: <br /> 19. For cocps permirs. provide namrs, addresses. and telephone numbers of adjoininB property ownets, lessas. etc., <br /> PLEASE NOT'E: Shoreline menagemmt compliance may roquire additioeal aotice— consult your local govecnment. <br /> SECTION C - Complete for any permit caverod by this appliatian <br /> 20. Application is hereby made for a pe:mit or pe�ib w autboriu the acavitia dacribed hereia. I ceRify that I am <br /> familiar wit6 tbe informuian conhimd ia thia applicadoa, aod that to the bae of my lmowlad�e aad belief, such <br /> information is true, complete, nad accunte. I litrther ce:tify Mut I poaess the authoriry w undertalce the propoxd <br /> activitia. I hasby gcmt co the agmciw W which 's appGcatioa is m�de, the right W mter the above-detcribed loca6on <br /> to iaspect the proposed ar compl worlc. _ <br /> C�t � - � 5- � � . <br /> Signaturc of Applicaut or utho ' Agwt (REQLJIItID) Date <br /> Si�ature of Iandowner (REQLTIREp if other tlun applicant) Date <br /> 77us applica[ion misst be signed by the applicant. If aa authoriud ageat is to be designated, the applicaet must alao sign <br /> at Item J13. <br /> I S U.S.0 ¢3001 provides tbu: Whoever, in aay manner aithin the juriidieaoo of�ny dcpt[m�eac or��eocy of 1he Umoed Suw Imowin�ly <br /> filsi6�s, conceals, or covas up by any triok, scheme, ar device a m�tetial faot or m�krs iny faLe, fiedawi, at 5au�leat meemeats or <br /> reprcsenutons or maka or uses �ny false wridnQ or documeat lrnowinQ same to cowia aoy fabe, ficdtiau, ar �w�leat atuemrnt or <br /> entry, shall be fined not more man 510,000 or irtWrisoned na ma[e Ih�o 5 yncs or bdh. <br /> �IQ <br /> 1 <br /> AppGcatioo Page 4 of 5 <br />