20201658 Ver 2_AGENT_AUTHORIZATION_FORM (Signed)_20220301

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. ______________ PLAN NO. ____________PARCEL ID: ________________________
Qjqfmjofdpssjeps-cfuxffoDbspmjobGpsftuCpvmfwbseboeIjhixbz28jo
STREET ADDRESS: _____________________________________________________________
PotmpxDpvouz-OpsuiDbspmjob
_____________________________________________________
Please print:
QjfenpouObuvsbmHbt)ipmefspgfbtfnfou*
Property Owner: ________________________________________________________________
KfsfnzNfbet)Ts/EjtusjcvujpoQspkfduTqfdjbmjtuxjuiQjfenpouObuvsbmHbt*
Property Owner: ________________________________________________________________
The undersigned, registered property owners of the above noted property, do hereby authorize
QbusjdlL/NfjfsCvsot'NdEpoofmm
__________________________________, 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.
Property Owner’s Address (if different than property above):
216JnqbduCpvmfwbse-Fmj{bcfuiDjuz-OpsuiDbspmjob38:1:
_________________________________________________________________
)363*375.8116
Telephone: _____________________________
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Jeremy Meads
_______________________________________________________________________
Authorized Signature Authorized Signature
3/1/2022
Date:_______________________________ Date:_______________________________