20201709 Ver 1_Agent Authorization_20211006

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCR P` ON: J/
LOT NO. PLAN NO. PARCEL ID: `I I ZiO-3
STREET ADDRESS: 7 lC-✓ F,— /
QC 22� 11-7
Please prim:
Property Owner.
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
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(Contractor / Agent) (Name of consulting firm) -Poll
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):
Telephone: —cam — 2 6
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
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Authorized Signature
Date:.