20230835 Ver 1_Agent Authorization_20230613

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. I PLAN NO. PARCEL ID: DUI 13 2 3 S
STREET ADDRESS: Z 0(` Z W I {� !:Kn CJ Pt f ty, , ( Lyn(I I L4f N(,
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
120yldu U l T-11 , of WClA1JSIU Maf $ �l cu
(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):
18 E D) NCL'k0 C Cat bKk f 2&01
Telephone: (D -1� I
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
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G^v
Au(hori d " natur Authorized Signature
Date: 412 S j Z CZ3 Date: 4
D J-V)D S E11 U NE- Kerby El 7Ti