20140306 Ver 1_More Info Received_20140402

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: L-.A,) S 0 - I -7
0
STREET ADDRESS: 10-1 M F gsccw cT
Ckg u ivc. a -15-19
Please print: t`,° I 1 I 1- t
Property Owner: V�► I Ar /A 1A i Ve-
Property Owner: �-�S I- 7 A/AJ6 LGf-
The undersigned, registered property owners of the above noted property, do hereby authorize
(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: `/ / -DI 6/-0/5-9
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: `"f - � 20 1 y-
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