20231158 Ver 1_Agent Authorization_20230822 (2)

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION;
LOT No. 5 T2 2. PLAN NO. f' PARCEL M., Z D '-2 314
STREET ADDRESS: _(r Q#mil IU, WA,*
LL iV C ]
Please pant:
Property OWrMf:
The undersigned, regiSteMd Property owners of the above noted property, do hereby authorize
(Contractor I Agent) (Name of consufung TIrmy
to act an my behalf and take ali Actions necessary for the processing, Issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Pr� Owner's Address (if different than property above).
Telephone:
We hereby certify the abow information submitted in this application is true and accurate to the
best of our Ivwowledge,
A660rized S7*k-dare Authorized Signature
Date: g Date: