20211577 Ver 1_add info received 12-16-2021_20211116

PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
STREET ADDR
Please print: nn
Property Owner: uY
Property Owner:
AGENT AUTHORIZATION FORM
PARCEL ID:
1�C
The undersigned, registered property owners of the above noted property, do hereby authorize
Y of
[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.
Props Ow is Address (if differ nt th n property above):
9 V, D� 6 pto n W
Telephone: $2 J k 2 -1
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
kWyrize Sig ature
Date: UV
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Authoriz d Signature
Date: 2 l Zl

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