20231129 Herrnstein

AGENT AUTHORIZAIION FORM
PROPERTY LEG �L DESCRIPTION:
LOT NO. PLAN NO,
ID: I3_L-
The u steed property owners of the above n 3ted property, do hereby authorize
er Lv_sk .of La 0� )rmo,7n �vecC 1;2�
(Contractor Mt) (Name of o msulting firm) J
J
to act on my be calf and take all actions necessary for the pr xessing, issuance and acceptance of
this permit or cE tification and any and all standard and spe(ial conditions attached.
Property Owner : Address (if different than property above):
'tom
M &OM
We hereby certi ,, the above information submitted in this
best of our knot ledge.
Date: v( � It G >
ClI%PdI ka ah6otC01
is true and accurate to the