20231182 Ver 1_Site Plan_20230825

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCR'pl"')N; r
LOT NO, PLAN NO..
PARCEL ID: , 05� 7 6C4 16 I qC!
STREET ADDRESS: C I+i ✓�'�+a A t�/ --_ _
Pease print: -
Property Owner:
Property owner;
The undersigned, registered property owners of the above noted property, do hereby authorize
of
(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):
IP() 130), 2-�-L/(� a..wd4De iV.c-, 2?127
Telephone:
TIP ,2 20 2-a 9fl
We hereby certify the above information submitted in this application is true and accurate to tt e
best of our knowledge.
ty
Authorized ature
Date: O
7 2
Authorized Signature
Date:�-
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