20211379 Ver 1_Agent Authorization Letter_20211006

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 5 PLAN NO. PARCEL ID: —154 V 1S 3 't 3 z
STREET ADDRESS: 139 NO2-1-0 N 21 t2_0
VA 1 C fit- Ac�T� 5 C. Z. S-1 `
Please print:
Property Owner: \r-J h--t
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
t T) t LP>.Ct. , of C EIC v-STO ,
(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):
I2,Zq . 5 c L- S Ac-eA SC Th 1 F L. 3`4-t 39
Telephone: q`{ k • 321 • S l $�
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
thorized Signatufe
Date: a L93 '-
Authorized Signature
Date: