Exhibit_E3_-_01a_Section_A_-_signature_page_(2024-07-08).pdf

PDF 146 KB Posted

Attached to
Design Services for Veterans Memorial Blvd. Phase II
Solicitation number
26-8668
Issued by
Collier County, Florida

About this file

This is a signature page from Form 62-330.060(1), an Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and Authorization to Use State-Owned Submerged Lands, submitted by Collier County Transportation Engineering Division in Florida. The document serves as the authorization and certification section of an environmental permit application related to the Design Services for Veterans Memorial Boulevard Phase II project. Jay Ahmad, P.E., acting as the Transportation Engineering Division Director, signed the application on July 10, 2024, certifying that the information contained within is true, complete, and accurate. The applicant acknowledges that this constitutes an application and not a permit, and that any work performed prior to approval would constitute a violation.

The signature page includes three critical certifications: Part A contains the applicant's acknowledgment of the permit application requirements and representation of data accuracy; Part B documents the applicant's certification of sufficient real property interest and authorization for agency staff to access, inspect, and sample the project lands and waters as necessary for permit review and compliance monitoring; and Part C designates RWA, Inc. as the authorized agent to act on behalf of Collier County in processing the permit application and furnishing supplemental information as requested. The document confirms that all parties understand the implications of false statements under Section 373.430, Florida Statutes, and 18 U.S.C. Section 1001.

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Text version

Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and Authorization to Use State-Owned Submerged Lands Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date 12/22/2020) Section A, Part 4: Signatures and Authorization to Access Property

Instructions: For multiple applicants please provide a separate Part 4 for each applicant. For corporations, the application must be signed by a person authorized to bind the corporation. A person who has sufficient real property interest (see Section 4.2.3(d) of Applicant’s Handbook Volume I) is required in (B) to authorize access to the property, except when the applicant has the power of eminent domain.

A. By signing this application form, I am applying for the permit and any proprietary authorizations identified above, according to the supporting data and other incidental information filed with this application. I am familiar with the information contained in this application and represent that such information is true, complete and accurate. I understand this is an application and not a permit, and that work prior to approval is a violation. I understand that this application and any permit issued or proprietary authorization issued pursuant thereto does not relieve me of any obligation for obtaining any other required federal, state, water management district, or local permit prior to commencement of construction. I agree to operate and maintain the permitted system unless the permitting agency authorizes transfer of the permit to a different responsible operation and maintenance entity. I understand that knowingly making any false statement or representation in this application is a violation of Section 373.430, F.S.

and 18 U.S.C. Section 1001.

Jay Ahmad, P.E. ________________________________ Typed/Printed Name of Applicant or Signature of Applicant or Applicant’s Date Applicant’s Authorized Agent Authorized Agent

Collier County Transportation Engineering Division Director (Corporate Title if applicable)

B. Certification of Sufficient Real Property Interest And Authorization For Staff To Access The Property:

I certify that:

I possess sufficient real property interest in or control, as defined in Section 4.2.3 (d) of Applicant’s Handbook Volume I, over the land upon which the activities described in this application are proposed and I have legal authority to grant permission to access those lands. I hereby grant permission, evidenced by my signature below, for staff of the Agency to access, inspect, and sample the lands and waters of the property as necessary for the review of the proposed works and other activities specified in this application, upon advance notice. I authorize these agents or personnel to enter the property as many times as may be necessary to make such review, inspection, and/ or sampling. Further, if a permit is granted, upon advance notice, I agree to provide entry to the project site for such agents or personnel with proper identification to determine compliance with permit conditions and permitted plans and specifications.

OR

I represent an entity having the power of eminent domain and condemnation authority, and I/we shall make appropriate arrangements to enable staff of the Agency to legally access, inspect, and sample the property as described above.

Jay Ahmad, P.E. _______________________________ Typed/Printed Name Signature Date

Form 62-330.060(1) - Application for Individual and Conceptual Approval Environmental Resource Permit, State 404 Program Permit, and Authorization to Use State-Owned Submerged Lands Incorporated by reference in subsection 62-330.060(1), F.A.C. (effective date 12/22/2020) Section A, C. Designation of Authorized Agent (If Applicable):

I hereby designate and authorize RWA, Inc. to act on my behalf, or on behalf of my corporation, as the agent in the processing of this application for the permit and/or proprietary authorization indicated above and to furnish, on request, supplemental information in support of the application. In addition, I authorize the above-listed agent to bind me, or my corporation, to perform any requirements which may be necessary to procure the permit or authorization indicated above. I understand that knowingly making any false statement or representation in this application is a violation of Section 373.430, F.S., and 18 U.S.C. Section 1001.

Jay Ahmad, P.E. ________________________________ Typed/Printed Name of Applicant Signature of Applicant Date

2024-07-10T08:46:21-0400
AhmadJay
2024-07-10T08:46:07-0400
AhmadJay
2024-07-10T08:45:52-0400
AhmadJay

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