20231272 Ver 1_Minor Variance_20230917 (4)

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 'I— PLAN NO.
STREET ADDRESS: ( C)
Please print:
Property Owner:
Property Owner:
PARCEL ID: 416 M
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The undersigned, registered property owners of the above noted property, do hereby authorize
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(Contractor /Agent) (Name of consulting firm)
1
to act an 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):
Telephoner 1 (n _ Z � 1 f
We hereby certify the above information submitted in this application is true and accurate to the
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Authorized Signature
Date: