20240218 Ver 1_More Info Received_20240223

AGENT AMORIZATION FORM
PROPERTY LEGAL DESCRWTION:
LOT NO. -r© PLAN NO. PARCEL ID: 113 2 R
STREET ADDRESS: +041 2 4rz 31uQ+ 0 J-
016rIJ lk AU r^ 'Rip )t
Please print:74hI1 Property Owner-.
The undersigned, registered property owners of the above noted property, do Hereby authorize
(� h td 44 o41r� of SE�1,1� ton c ��I�a��.�c t-t-
(Contractor / Agent) (Name of mrsuRing 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):
Telephone: -1o3 - C) I ' cIM F ci
We hereby certify the above information submitted in this application Is true and accurate to the
hest of our knowledge.
AuthorizedSignature
Date: f LI
Authorized Signature
Date: