20230452 Ver 1_Agent Authorization_20230328

AGENT AUTHORIZATION FORM
PROPERTY LEGAL: MSCRIPTION.,
LOT N0--,, 31— , — PLAN -W � , PARCEL ID- Qb. 15 3. 1, !.�
STRE8fA00R%S' 103.1. 40
Please print;
Property Owner
Property Owner:
The undersigned,. rejjjs�ered pm" OM" 0 1 f" above nbtedproe4 do W* aWMze
ESQ - of C-GC S±-One- E; 31&-QC1)4..LLC-
(Contractor / Agent)) (Name W.consulting -firm) ---J T-
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 11�rfs Wrest (JUdiffenent than property above).-
Telephow..
We hereby certif)(the above, lnfbrmation submitted in this application is true acid accurate to the
0W. of our knowledge.
Dal' .
A4t `iced *P*tre
Date,.