20141045 Ver 1_More Info Received_20141014

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: _ 0 9 - IZ- gVZ -6cw
STREET ADDRESS: 0L7 WitqFtscp -ir US
AmP rr L
Please print:
Property Owner:
Property Owner:
m1flk vioza pie
The undersigned, registered property owners of the above noted property, do hereby authorize
of T7y�s n1F"%'. Ff2':G2('7
(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):
ylo 5 01 L-,,,.4,,,r �, S� -W-T �a� si�N, NG 2'7(,01
Telephone: 91 q- 54 is - 3 C) 70
We hereby certify the above information submitted in this application Is true and accurate to the
best of our knowledge.
r�
Author.' g e
Date: t &1 141
Authorized Signature
Date: