20231301 Ver 1_Site Plan_20230921 (2)

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO, PARCEL ID:
STREET ADDRESS: 171 Ln W-1 So�__, nnojU Q is {�j� nC'j1 —Or
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
)Q1YlIrP 11C,
(Contractor Agent)- of (NamCeof consulting firm
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1pmto 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):
Telephone:. EM - 3ba - a q rjD
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: 9/8 /2
?,rized Signature
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