20230685 Ver 1_Agent Authorization_20230515

AUTHORIZATIONAGENT
Please note that multiple forms may be necessary if there are more than two owners of the property.
STREET ADDRESS OF EXISTING HOME or LATITUDE/LONGTT1 IDF OF NFIA! rnNCZTDI irrrnni.
Parcel ID: 61 3FIE'579. 000
Property Owner Names) — please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Tina C. Little
(Contractor/Agent)
, of Little's Lake Permit Services LLC
(Name of company)
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 Owners Mailing Address (if different than property address above):
Property Owner(s) Telephone: -.-V , ,
We hereby certify that the above information submitted in this application is true and accurate to the
r knowledge.
Authorized Signature
Date