20231020 Ver 1_Agent Authorization_20230724 (3)

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCUMON:
LOT NO. ,3 3 3 -PLAN NO. PARCEL ID: �_� q d_
MEET ADO ESS: 53 Gr-415S, � Vw
t[ C 8r'Za
Please print: C
Property Ovrier. _ TJ L1..A ri ,(Ip N
Property owner: ) f}r+CA—
The undersigned, rred property ovrners of the above noted property, do hereby author¢e
(CanowW I Agent) (Name of consulting fkm)
do act on my bF rialf and take all actions necessary for the processing, issuance and acceptance aF
this permit or certifrcadon and any and all standard and special conditions attached,
Prwerty Owner's Address (if different than property above);
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Telephone(30! ,) 1ti a -> I
We rrereby certify the above infort ubon submitted m tNs application is true and accurate to the
nest ul< our krxjrvleclge.
Aud-iorired Signature
Date: