400 RIVERSIDE RD SEPA 016 - 039 - RIVERSIDE BUSINESS PARK Land Use Decision Documents 2025-04-14

Part 11-Authorizing Signatures Signatures are required before submitting the JARPA package.The JARPA package includes the JARPA form, project plans, photos,etc. (helot 11 a.Applicant Signature(required) thebl 1 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 autho ' e agent named in Part 3 of this application to act on my behalf in matters related to this application. (initial) 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 enteri • tjtte property where the p oject is located to inspect the project site or any work related to the project. b: (initial) Dave Kessler - - r2-e 16 Applicant Printed Name 4plica ignature Date 1 lb. Authorized Agent Signature rniool 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. Jeremy Downs f -- Date — Authorised Agent Printed Name Au t • a Agent S _ a Date 11 c. Property Owner Signature(if not applicant) Not required if project is on existing rights-of-way or easements. 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. j PriS erty-fe nerP ted Name Prop Signature Date l..47r3cyr,r 18 U.S.0§1001 provides that:Whoever,in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies,conceals,or covers up by any trick,scheme,or device a material fact or makes any false,fictitious,or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false,fictitious,or fraudulent statement or entry,shalt be fined not more than$10,000 or imprisoned not more than 5 years or both if you require this document in another format,contact the Governors Office for Regulatory Innovation and Assistance(ORIA)at(800) 917-0043. People with hearing loss can call 711 for Washington Relay Service.People with a speech disability can call(877)833- 6341. ORIA publication number ENV-019-09 rev.09t2015 JARPA Revision 2915.1 Page 18 of 18