11807 SILVER LAKE DR 2024-01-05 - Laserfiche WebLink

Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. melpl 11a. Applicant Signature (required) firski I certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities, and I agree to start work only after I have received all necessary permits. I hereby authorize the agent named in Part 3 of this application to act on my behalf In matters related to this application. DS (City of Everett lnkiag By initialing here, I state that I have the authority to grant access to the property. I also give my consent to the permitting agencies entering the property where the project is located to inspect the project site or any work related to the project. ns (City of Everett initial) Dean Shaughnessy Dean Shaughnessy prghally:Ig Nby Dean shaugli 9 Y oare::an.w.vossens 07W Applicant Printed Name Applicant Signature Date 11 It. Authorized Agent Signature Ji I Certify that to the best of my knowledge and belief, the information provided in this application is true, complete, and accurate. I also certify that I have the authority to carry out the proposed activities and I agree to start work only after all necessary permits have been issued. Jason Walker 12117/2021 AUNodzetl Agent Printed Name A t zed Agent Signature Date 11c. Property Owner Signature (H not applicant) pearl) Not required if project is on existing rights -of -way or easements (provide Copy of easement with JARPA). I consent to the permitting agencies entering the property where the project is located to inspect the project site or any work. These inspections shall occur at reasonable times and, if practical, with prior notice to the landowner. N/A Property Owner Printed Name Property Omer Signature 18 LLSC §1001 provides that: Whoever, In any manner within the jurisdiction of any department or agency of the United States knowingty falsifies, conceals, or covers up by any trick, scheme, or device a material fact or makes any fake, fctltlous, or fraudulent statements or representations or makes or cases any false writing or document knowing same to contain any false, fcgtious, or fraudulent statement or en", anall be fined not mare than $10,000 or imgisoned not more than 5 years or both. II you require this document in another turret, contact the Oovemols Office her Regulatory Innovation and Assistance (ORIA) at (800) g17-Oo43. People with hearing loss can call 711 for Washington Relay Service. People with a speech disability cep call (877) ass- 8301. ORIA Dubleation number: ORIA-18-011 rev. 0912018 ARIA-rvAnc rW020 Ptge 14014