20211861 Ver 1_Agent Authorization_20211222 (2)

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
Wy
1:71.021a0-11a] 7.1=31
PLAN NO.
M
Please print: �^ me"
Property Owner: +�"� r ■ `
Property Owner:
PARCEL ID:
d • --f;;D N R2 7'131 I
The undersigned, registered property owners of the above noted property, do hereby authorize
1 ftLAY -,of f4mi
(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):
Telephone: qjn . S r r l r 03
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
u horized Signature
Date: Z !�
Authorized Signature
Date: