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NOTARIZED STATEMENT <br />I, (the undersigned applicant) under penalty of perjury in the State of Washington agree to <br />comply with all sections of this document, federal, state, and local provisions, codes, and ordinances in regards to water use. These <br />covenants and agreements shall be binding on all parties having or acquiring any right, title, or interest in this land described <br />herein or any part hereof and it shall pass to and be for the benefit of each owner thereof. I certify that the information provided is <br />true and accurate and I understand that if the project description should change that it is my responsibility to inform Kittitas <br />County Public Health Department (KCPHD) and that the department may require different and/or additional requirements. As the <br />applicant, I assume all risk in its entirety and agree to indemnify defend and hold Kittitas County, its departments, elected and <br />appointed officials, employees, and agents, harmless from and against any and all claims, damages, losses and expenses, including <br />reasonable attorney's fees, for any bodily injury, sickness, disease, or death, or any damage to or reduction in value of property <br />including the loss of use resulting there from which are alleged or proven to be caused in whole or in part by a negligent act or <br />omission of its officers, directors, and employees. As the applicant, I understand that I am legally and financially responsible for <br />ensuring there is a legal right to the water to be used, and that all water supply systems are engineered, designed, and constructed <br />in accordance with federal, state and local requirements. I understand that all applicable fees may be non-refundable and that <br />KCPHD may have additional requirements to ensure that sufficient and adequate water supply is available for use and I shall <br />comply with all requests made by KCPHD. Should I as the property owner choose to use and appoint an authorized agent to <br />represent my interest, I may do so, by having myself and the authorized agent sign this notarized statement. <br />Signed: Property Owner(s) <br />Print Name: <br />Property Owner(s) <br />-(the property owner) appoint, <br />as an authorized agent to represent my interest. <br />Authorized Agent Signature (if applicable): Print Name: _ <br />Authorized Agent Authorized Agent <br />State of Washington <br />)ss <br />County of ) <br />1, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this day of <br />. 20_, personally appeared before me, <br />who is personally known to me <br />whose identity I proved on the basis of <br />whose identity I proved on the oath/affirmation of a creditable witness <br />to be the signer of the above instrument, and he/she acknowledged that he/she signed it. <br />to me known to be the person(s) described in and who executed the within and <br />foregoing instrument, and acknowledged that he/she signed the same as his/her voluntary act and deed, for the uses and purposes <br />therein mentioned. <br />Witness my hand and official seal hereto affixed <br />Notary Public in and for the State of Washington, <br />Residing in: <br />My Commission Expires: <br />�yi �Oti ` 'fj •tir <br />507 N. Nanum Street, St. io2 - Ellensburg, WA 98926 <br />T: 509.962.7515 • F: 509.962.7581 <br />www.co.kittitas.wa.us/health/ <br />