20240563 Ver 1_More Info Received_20240521

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AGENT AUTHORIZATION FORM
PROPER-1Y LEGAL DESCRIPTION:
LOT NO. { PLAN NO. �" PARCEL ID: 30 (v y 3
STREET 71 S Z Gil A,'3 u e--L.yl ew Q e c vL
Please print:
Property Owner° ::T—A M tf:<51 D u e & tit
Property Owner: C510- . _AA VS.;
The undersigned, registered property owners of the above noted property, do hereby authorize
L(, 4 ALV,k of )4&- &A-1I -r L"r-
(Contractor / Agent) (!Name of consulting fine)
to act: on any 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):
SA-ey e. AvMt VIE -
Telephone: _-761( - 0 5. 2E2 a
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
3,�
on . Signature Au rized Signature
Date- Date: l