20230454 Ver 1_Agent Authorization_20230328

AGENT AUTHORIZATION FORK
PROPERTY LEGAL DESCRIP i ION:
LOT N0, I PLAN NO. PARCEL ID:
STREETADDRESS: ! LD I ICa [.e.(- 6n Lc-x�p
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PropertyOwner: Lo—u rte-n i a
Property Owner:
The undersigned, registered property owners of the above noted property; do hereby authorize
of C80— e � Re I_I�.0 Ii nq 11C
(Contractor / Agent) I (name of consulting firm) J —J,
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: J W T a,Ci 3 4 507
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: �'d �j Date: