J-4_Exhibit_3_Revocable_License_to_Cross_Tulalip_Tidelands_Application_4_pages.doc

Application Number

OWNER/ (Please print clearly)

The Tulalip Tribes

Community Development

6319 23rd AVE NE

Tulalip, WA 98271

Telephone: (360) 651-3861

The applicant is required to provide a proof of the surety such as bond, insurance, or other surety representing a minimum of 125% of the value of the work (prior to submitting the application), mitigation report, survey, etc.

Make check payable to: The Tulalip Tribes

APPLICATION FEE

(non-refundable) $ 300.00

This is an application for a revocable license to cross Tulalip Tidelands for construction as authorized in Tulalip Ordinance 129, section II.C.5. By signing below, the applicant acknowledges that this license is revocable at will and in the sole discretion of the Tulalip Tribes, and nothing in any revocable license issued by the Tulalip Tribes creates any property rights for any person, or conveys any property rights of the Tulalip Tribes in any manner whatsoever.

Authorization to be issued to:

Date of Application

Home Address (Street or Route, P.O. BOX) Telephone Number

City, State, Zip Fax Number

Applicant’s Representative:

Telephone Number

Home Address (Street or Route, P.O. BOX)

Fax Number

City, State, Zip

IMPORTANT PLEASE NOTE:

NO WORK CAN BE STARTED ON THE PROJECT AREA UNTIL the applicant has complied with all requirements in Ordinance 129 and revocable license to cross tribal tidelands for construction has been issued to the applicant under the authority of the Tulalip Board of Directors.

LOCATION:

Physical description of Project Area (For example, Marsh, Tideflat adjacent to Ebey Slough Creek, etc.):

Name of Owner(s) of Uplands, Shorelands, and/or Tidelands shoreward:

Telephone Number

Fax Number

Home Address (Street or Route, P.O. BOX

City, State, Zip

Legal Description of Property (Section, Township, Range): Please attach complete description.

Upland Site Acreage:

Present use of the Upland Property:

USE OF TRIBAL TIDELANDS: Type of proposed use of Tribal Tidelands and identify additional proposed use, if any.

1. Physical description of Corridor Area (For example: Tidelands at Mission Beach, Marsh, Tideflat adjacent to Ebey Slough Creek, etc.)

2. Type of physical improvements or structures that currently exist on the shoreline above Tribal Tidelands.

3. If there are physical improvements currently on the shoreline, who holds ownership to them?

4. If there are physical improvements currently on the shoreline, describe their condition.

5. Which of the existing physical improvements will be removed, remodeled, or reconstructed?

6. Type of physical improvements or structures that you are proposing to construct on the shoreline above Tribal Tidelands.

7. Value of proposed improvements or structures:

8. Who will ultimately be served or benefit from this project?

9. Proposed construction starting date:

Completion date:

10. Length of time requested for access to Tribal Tidelands.

11. Length and width of the work corridor area.

12. Boundaries of site disturbance: (Show the limits of disturbance on the beach that will be created by equipment operations and storage, including barge, material stockpiles, wood piling removal and debris stockpiles, etc.)

13. Supplemental documents (provide copies of county assessors information relating to parcel numbers, a legal survey plat of the construction site and work corridor areas, engineering drawings, site plan of work corridor areas, photos, copies of all government regulatory permits (County Shoreline Permit, HPA, SEPA, etc.)

14. Detail the construction practice, procedure, stockpiling of materials, and proposed location of the excavation materials, vehicles, and equipments during low tides with erosion and sediment control. You may use the questions a – h as a guideline:

a. How will the heavy equipment and materials be transported to the construction site?

b. How much volume of heavy materials will be hauled to the site?

c. How will the excess materials be relocated off site?

d. How many current wood pilings are to be removed?

e. How many total linear feet of current wood pilings are to be removed:

f. How will the current wood pilings be removed? (Detail the method of removal and the disposal of wood pilings that will be removed)

g. Will there be any large organic debris and rocks placed on Tribal Tidelands while the structure (i.e. bulkhead pilings) is under construction?

h. Do you have any knowledge of contamination of the site by toxic or hazardous substances? If so, please explain.

15. Describe any habitat mitigation and identify where such mitigation is proposed to occur.

SIGNATURE: This application may be rejected at any time before signed execution of a use authorization.

I hereby certify that I have prepared this application and site plan and that to the best of my knowledge the information provided is complete, accurate, and a true representation of the proposed development. I further attest that I have the authority to submit this application and agree to comply with any and all conditions of development permit approval. I agree to provide any additional information required and understand that if the scope of the project is modified, a new application may be required.

Signature(s) required

X Title

Date

Date

Date

Application prepared by (please print) Title

Telephone Number

Date

Staff Notes:

Application for Revocable License to Cross Tulalip Tidelands

Please type or print clearly in dark ink.

A

B

C

D

E

F

PAGE

Application for Revocable License to Cross Tulalip Tidelands

Revised 10/2006