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� + <br /> irr�� <br /> �r�� NOTICE 4F IN�'ENT (NOf) Check if appficable: <br /> APPLICAT[C3N F4RM ❑ Change/Upda#e Permit <br /> wasntxcrax s�nrt (C1�OI'Cllr�flpll <br /> . OEFtAf�itf NI -0f � � � � � � � <br /> � � � � � � '� Construcfion Stormwater General Permit ❑ Mod�ficat�on af Perm�t <br /> Goverage <br /> Permit#WAR <br /> Please print or type legibly al!sections of ihis appliaation. <br /> I. Operator/Permittee II. Site Owner <br /> �perator: Person who has operaEionat contral over <br /> plans and specificafions and/or has day-ta-day {If different than Operator/Permittee) <br /> operational controf a#activities which ensure <br /> compliance with permft conditions. <br /> Name Bill Grady � Name <br /> Carnpany Bosa-Grady, LLC Company <br /> Unified Business lctentifier(UBI)801 594631 Unifisd Business Identifier{UB1) <br /> lndrviduals without a U81, enter none or non-applicable. Indivlduals without a UBI, enter none ar non-a licabl�. <br /> Mailing Address P.Q. Box 158 Mailing Address <br /> PO�ox (Optianal) PO Box(Optionaf) <br /> Gity Mukilteo Sfate WA Zip 98275 Cify State Zip <br /> Phpne Na. Business 425-355-7335 Ext. Phone No. Business Ext. <br /> Cell Cefi <br /> E-maif (Optianal) �-mail (Optiona!) <br /> Fax Na. O tiana! �'ax No. O fional <br /> 11f. On-site Cantact Person !V. Billing Infarmatian <br /> Same as Certified Erasion&Sediment Control Lead <br /> tVame Jeff Wright Name Roni Grady <br /> Title Site Supervisor Title <br /> Company KLB Construction Company Bosa-Grady, LLC <br /> Nlailing Address P.O. Box 158 Mailing Address P.O. Box 158 <br /> PO Box{Optiona(} PO Box{Optianai} <br /> City Mukilteo Sfate WA Zip 98275 City Mukilteo SEate WA Zip 98275 <br /> i'hone No. Business Ext. Phone Na, Business 425-355-7335�xt. <br /> Cell Celf <br /> E-mait (Qp#ionai) E-maiE (Opfional} �'�.�,t�taklbcc3l��-s-ac.+ier�.�o�Y, <br /> Fax No. O tional Fax No. O tional <br /> �.� <br /> �,..__ <br /> ,,�- <br /> ECY a2a-85(rev 12/05) �`�ge 3 � <br /> � � <br /> '^a-�� <br />