20201104 Ver 1_Agent Authorization_20201009

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: Zd Z✓' 09-
STREET ADDRESS: - _ /'Gll'�WLi�D � L nu mAr r N G
Z7S�
Plperty w LAkE 274114S? ONY aU�D
Property owner: _ . _ �� NG 2 LLB
t..:..3.mrrm
The undersigned, regetered property owners of the above noted property, do hereby authorize
oM ADS-, of 5i�ejNe-
(Contractor / Agent) /u (Name oLonsulting 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 sfaggar,Q,and special conditions attached.
Property Owner's Address (if different than prroa{y above):
I-eq2Wt�1s _ 21U 12_A+ZI RAZ-16Nr r/G Z71.14
Telephone:
We hereby certify the above information sybmitted in this application is bue and accurate to the
best of our knowledge. y,i k.
ll -
utho zed Sig n Authorized Signature
Date: ` 2,0 Date:
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