20211681 Ver 1_Agent Authorization_20211118

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. ( PLAN NO. PARCEL ID:
STREET ADDRESS: ._-al 2, (20l KNa3 O r .
�S�U-�es v , t f ' Rc a8 L11-1
Please print:
Property Owner: IA C i+�ie v mn
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
v
jo'n 1= r-aff.Dof
(Contractor J Agent) (Name of consulting fit)
to act on my behalf and tame 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: '10 q - C1Q 3, - 10 BBC
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Date:
r
uthorize SignatCure /�
Date: _ I