20171405 Ver 2_More Info Received_20230919 (2)

SAMPLE AGENT AUTHORIZATION FORM
LOT NO. PLAN NO.
PARCEL ID: S 2/ / I
STREET ADDRESS: 02 t d'L �a /' �/ l t -e ? O ' n'�
L C,�c L v ,-C N C— 0� 9 �, z/ (p
Please print:
Property owner:
Property Owner: D A (� %< EL n S
The undersigned, registered property owners of the above noted property, do hereby authorize
C r: C kV ^c,—f' \ , of X - P.�'t+� 0 n ve-:!s 1
(Contractor / Agent) (Name of consu ing firrn)
to act on my behalf 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):
IgS79 1-Pr►q (()12 L,ANc% M ILL 5Q�(PG VC 2,875/0
Tom:�-
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signatu72-
Au C
Da
te: 5 Date:
IN