1870 ROSS AVE SEPA 017 - 017 -DAGMAR'S BOAT LAUNCH DREDGE Land Use Decision Documents 2025-04-16

Part 11—Authorizing Signatures Signatures are required before submitting the JARPA package. The JARPA package includes the JARPA form, project plans, photos, etc. 11a. Applicant Signature(required) [itetnl 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. (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 entering the property where the project is located to inspect the project site or any work related to the project. X (initial) {� ttc (AO Applicant Pnnted Name / atu Applicant Sign Date 11 b.Authorized Agent Signature [ 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. Authorized Agent Printed Name Aut'.ionzed Agent Signature Date 11C. Property Owner Signature(if not applicant)[help] 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. Property Owner Printed Name t Property Owner ignature Date MA11,c�r'dt (VLa-ty 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,shall be fined not more than$10,000 or imprisoned not more than 5 years or both. I If you require this document in another format,contact the Governor's 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. ORIApublication number: ORIA-16-011 rev.07/2017 ORIA-16-011 Page 15 of 15