20230207 Ver 1_Agent Form_20230203

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION;
LET NO. J PLAN M PARCEL ID:
--�)o 5-M ADDRESS., A-1
Oqaoresv'lile,hic aswi
Please print: k
Property Owner- x,
Property Owner:
The undersigned,, roeg)stwed:pmperty oWners of the move rioted property, d6 herdby at ftrize
jiy%c e- 1�1` P - ! . .1 1 1 4 of -C-Be. &6. ne ecuc, I j -oa, LLC
(Contractor / Agent) (Name of consultiriq firm)
to act on ray beha and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above)
,,-
ai5 v
.4 m o giv, cores u'lie ,tic. agiri
Telephone: q9b -,y191 - 350a,
We hereby cer* the above information: submitted in this -application is true and twurate to the
best of our knowledge,
Authorized Signature
Date; I a- I g.0