Restoration Activities Near a Stream or Wetland - continued
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DevSvcs-PMC-1.1-20150605
STATEMENT OF OWNERSHIP/DESIGNATION OF AGENT
The undersigned property owners, under penalty of perjury, each state that we are all of the legal owners of the
property described in Exhibit A, which is attached as page 3 of this application.
Designated to act as our agent it with respects to this application:
AUTHORITY TO ENTER
I/we acknowledge that by signing this application I/we are authorizing employees or agents of the City of Kirkland to
enter onto the property which is the subject of this application during the hours of 7:00 a.m. to 5:00 p.m., Monday
through Friday, for the sole purpose of making any inspection of the limited area of the property which is necessary to
process this application. In the event the City determines that such an inspection is necessary during a different time or
day, the applicant(s) further agrees that City employees or agents may enter the property during such other times and
days as necessary for such inspection upon 24 hours' notice to applicant(s), which notice will be deemed received when
given either verbally or in writing.
HOLD HARMLESS AGREEMENT - READY CARFULLY BEFORE SIGNING
The undersigned in making this application certifies under penalty of perjury, the truth and/or accuracy of all
statements, designs, plans and/or specifications submitted with said application and hereby agrees to defend, pay, and
save harmless the City of Kirkland, its officers, employees, and agents from any and all claims, including costs, expenses
and attorney's fees incurred in investigation and defense of said claims whether real or imaginary which may be
hereafter made by any person including the undersigned, his successors, assigns, employees, and agents, and arising
out of reliance by the City of Kirkland, its officers, employees and agents upon any maps, designs, drawings, plans or
specifications, or any factual statements, including the reasonable inferences to be drawn therefrom contained in said
application or submitted along with said application.
I certify that I am the owner of this property or the owner's authorized agent. If acting as an authorized agent, I further
certify that I have full power and authority to file this application and to perform, on behalf of the owner, all acts
required to enable the jurisdiction to process and review such application. I have furnished true and correct
information. I will comply with all provisions of law and ordinance governing this type of application. If the scope of
work requires a licensed contractor to perform the work, the information will be provided prior to permit issuance.
PRIMARY CONTACT (APPLICANT)
Name/Signature
PROPERTY OWNER
Name/Signature
Alternate Formats: People with disabilities may request materials in alternate formats.
Title VI: Kirkland's policy is to fully comply with Title VI of the Civil Rights Act by prohibiting discrimination against any
person on the basis of race, color, national origin or sex in the provision of benefits and services resulting from its
programs and activities. Any person who believes his/her Title VI protection has been violated, may file a complaint
with the City.
To request an alternate format, file a complaint or for questions about Kirkland's Title VI Program, contact the Title VI
Coordinator at 425.587.3011 (TTY Relay: 711) or titlevicoordinator@kirklandwa.gov.
