20230580 Ver 1_Agent Authorization_20230711

AC ENT ALITHQR RATION FOR CAMIA PER M IT A PP LI ATION
Alame of Property Owner Requesbng Permit:
W iiing Address:
Phone Number:
Email Address;
oertifY that I have authofted
to -I on my ben alf, for the pu rpm of applying to r and obta fining all QAMA permit
pA � eL-r-
-7�q t 7.;P-
naoossaFy for V-,e fof lowing proper develDpment;
cc
at my property located at 6
in _ County -
AA DeM wf Le
I furtherrrrwe -cerhfy that f am avfha zsd to grant, and do on fact grant rrni S+orp to
Division of Comtal Msoagament staf. the Local Permit Officer and tha?f agents to eater
on the ofaramerlfioned lands in mnnedion wi#h evaluating informaliGn related Io M s
permit appiketfort,
Property Omer ]nformsMort.
IF
Segaeture
! r ',Sj Vr J-Toe-esr MPS
Print or Type Name
117f-
DOW
This oerlAc ation Lr� valid through 12- 1 Of ?