20221523 Ver 1_Agent Authorization Form_20230104

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LCGAL DESCRIPTION: Q,, !
LOT NO. PLAN NO. PARCEL ID: Zby / � W z s 000
STREET ADDRESS:
La k-Fu�bLu AGT ,6714
Pfease print.
Property Owner:
Property Owner
The undersigned, registered property owners of the above noted property, do hereby authorize
e of y l.\ic Q i�I1�� -( ihi -d c
(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: 9)50 • E4qF
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
u t !rpzed Signature
Date. -
Authori
zed Signature
Date:)-jI(?