20241475 Ver 1_Agent Authorization Form_20241025

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: / r
LOT NO. PLAN NO. PARCEL ID: ; �Z ' co - � �j�> Ij -o'00
STREET ADDRESS- h Ut COiCt J1(X.;nlCAA -K L
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Please print: ;
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
of �.in X� P2tin�s L)�c P>MV(j.'rd ,Ou, L
(Contractor / Agent) (Name of consulting firm)
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
-So s7l�
Telephone: -- ��7 -(a0
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
11Y��1"
Authorized
' Signature
Date: 1, V 17,