20151097 Ver 1_More Info Received_20151119

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
STREET ADDRESS:
PLAN NO. PARCEL ID: �?74!— 4 5—ql fog - 40 DD 7�
Please print: // �L /f
Property Owner: h e / CeS IPA'
Property Owner: F.eiGe icic.n,✓ Ce- Ce
The undersigned, registered property owners of the above noted property, do hereby authorize
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de,,W-&j of 4•tL �. 501°�'��" �t�/�' �Y.�
(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):
Telephone: VA? - 6 F3 — Vq9 ?
We hereby certify the above information submitted In this application is true and accurate to the
best of our knowledge.
Aut orized Signature Authorized Signature
Date: /0 - 31— /S Date:
�OV 19
20I5
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