Form ENLS-651-021B "Designated Engineer/Land Surveyor Affidavit" - Washington

What Is Form ENLS-651-021B?

This is a legal form that was released by the Washington State Department of Revenue - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Washington State Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ENLS-651-021B by clicking the link below or browse more documents and templates provided by the Washington State Department of Revenue.

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Download Form ENLS-651-021B "Designated Engineer/Land Surveyor Affidavit" - Washington

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Designated Engineer/
Land Surveyor Affidavit
I,
, the undersigned, on my oath
Name of designated professional engineer/ land surveyor
first being duly sworn, state that I am registered as a professional
,
Engineer/ Land surveyor
license number
. On
, 20
, I was named as the
Date
professional
in responsible charge by a resolution of the Board of
Engineer/ Land surveyor
Directors, or company manager(s) of
.
Corporation or LLC name
I understand that this designation makes me responsible to ensure the firm’s engineering and/or land surveying
activities are in accordance with Washington State law. I further state that I am an employee of said firm and
that I am not designated as the professional in responsible charge for any other firm or business
in the state of Washington. In the event I cease to serve as the
Engineer/ Land surveyor
in responsible charge, I shall provide written notice to the Board within 30 days of such change.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
(Professional engineer seal)
TYPE or PRINT Name of designated professional engineer
X
When you have completed this form, please print it out and sign here.
Date and place signed
Signature of designated professional engineer
(Professional land surveyor seal)
TYPE or PRINT Name of designated professiional land surveyor
X
When you have completed this form, please print it out and sign here.
Date and place signed
Signature of designated professional land surveyor
ENLS-651-021B (R/1/16)WA Page 1 of 2
Click here to START or CLEAR, then hit the TAB button
Designated Engineer/
Land Surveyor Affidavit
I,
, the undersigned, on my oath
Name of designated professional engineer/ land surveyor
first being duly sworn, state that I am registered as a professional
,
Engineer/ Land surveyor
license number
. On
, 20
, I was named as the
Date
professional
in responsible charge by a resolution of the Board of
Engineer/ Land surveyor
Directors, or company manager(s) of
.
Corporation or LLC name
I understand that this designation makes me responsible to ensure the firm’s engineering and/or land surveying
activities are in accordance with Washington State law. I further state that I am an employee of said firm and
that I am not designated as the professional in responsible charge for any other firm or business
in the state of Washington. In the event I cease to serve as the
Engineer/ Land surveyor
in responsible charge, I shall provide written notice to the Board within 30 days of such change.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
(Professional engineer seal)
TYPE or PRINT Name of designated professional engineer
X
When you have completed this form, please print it out and sign here.
Date and place signed
Signature of designated professional engineer
(Professional land surveyor seal)
TYPE or PRINT Name of designated professiional land surveyor
X
When you have completed this form, please print it out and sign here.
Date and place signed
Signature of designated professional land surveyor
ENLS-651-021B (R/1/16)WA Page 1 of 2
Corporation/Limited Liability Company Resolution
On
, 20
,
who is currently licensed as a
Date
Name of designated professional engineer/ land surveyor
professional
in the state of Washington under license number
,
Engineer/ Land surveyor
was appointed the designated licensee in responsible charge for the practice of engineering and/or land surveying
performed by
.
Corporation or LLC name
The designated licensee has full authority to make all final engineering and/or land surveying decisions on behalf
of this firm for such work performed for projects in the state of Washington.
This resolution further states that the bylaws of the corporation or limited liability company agreement shall be
amended in accordance with RCW 18.43.130 pertaining to engineering or land surveying decisions made by the
designee.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
TYPE or PRINT Name of corporation officer or LLC manager
Title
X
When you have completed this form, please print it out and sign here.
Date and place signed
Signature of corporation officer or LLC manager
ENLS-651-021B (R/1/16)WA Page 2 of 2
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