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HomeMy WebLinkAbout71840D - Baginski AGEN AUTHORIZATION FOR CA IA PERMIT APPLICATION Nam<< rY. A 1/�'Ctr1!. ,�r rty 0j # ne f2aqu4Pst'.^ng Perrni Phon,ciJumoe.- Email Addres,�' I certify t�•at ' have authorizea AgLrit i Cort:�•_��5; to act on my behalf, zo, the pug3ose Qi appiylncg fvr and obtaining all CAMA Dermits nc,cessa7�, for the fill©nri �c� Ar�,f;;sLc ,:;evelat��`,rnt I—i XG a (:: � C) 6 ev q 11, C, I( cat'nv oroPerty locateC n, ! 1 >`ti►tr?=+;!7if?fi �'Sri;fi! Iy?ii1 r ;';} iii0!ized tc CjfdRt, and {}t3 i1� IzdCf 4�r�3,'7( j:t'dfRi �rof� 7Gy Li) �.r�srt � �i G�uSt ? ('>r?anagarrreni staff, )e `ot.a! Perrrtrt Officer aad their agonts to enter on iiiN :" ]fix,'r1@r7iaoli j' tF nd—,; it? comiigcttnjj 1.vith e,,"atualina ;nfOrIftlation related to Hus perrrIn a po ica t: cr Property Owner Worrna:ior.: Ponr of �,ac tllarr,F — r3:,tr_ I his cei lif rcatio't is •,,rakf throe^% AIIJ qE -NL�ilpAR�—AN PROPERTY OW, -'RsTATE,'jjj-NT �NArre 0 Pr C ty ovmer NA I'JRAW�il f-0- 2-310MAPI�; Lot, Block. "load .,ti- -01 -L :,snt't 7!0' tl'p de .1 , the pwvwlc I'c Ino, c-E-SCRIPIi AN'DiOR L-)RA,'VVt&C, Or- PROPOSED IDEVELOPM tiT v elow" Dn t in r;s t !I'11 ire dU attach a sde drawing! under WAIVER SECTION, S a tIat - mirim-tr %isiFfce 0c'-q m y ; Wusl be Sol b,3--A F ; a r a Zi �'!I k1f Must initial tIne dc; not N ei-'i to -I Ijr'-)P0,rtY Owner Infarmatiori I N.; Lva L VIC, 4 -7. 5 6 r!Y Owlfle- Irformationi 2 3LA W �� I U, T!O ull I �Vjl-lzl idOJd) 't, — ac� , —vwui -�..—;naj- -Ji.- 1.�,e 1 'Ut.tucc, j:l, f-,' O I J-o U if&iq PAII-l" I 71-0—U-57IM-NOO ou se aturi 02 Cl!"W UVZ7 SOA *e4Vd-tadoj vu riq ?e3 Soo:) ;c 4•"114S.I.111.7 a4j Ap4a �; 15 r(!I, s U'l ?)Nv lk:.. j A41 - F, . .1 LLB} .,.-) )' C'� !.� . �7 I", 31-4 A 0" Q315? nn 3 6 1 cal Tj N 54 _rIL 37-ij Cl D I A- I I L4 i—I:D MEN 0 MENEM ONE 0 NEON No ONE 0 no w No Ml, 4 n VV Date Received Date Deposited Check From (Name) Name o1 Perm/t NOMer Vendor Check Number Check amount Perm/t Numbwncomments Receipt or Relun&Realfocated Column) ColumnY Column3 Column) __ Columns C.I... Column? Column. Column. 10129r2Ql9 10(29W19 MCPh rs nManne nh Ph m inski Firs Ri ens an 9 'GPp71840 IT r 19