20171062 Ver 1_Agent/Consultant Authorization Letter_20170824

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. .�'l PLAN NO. � PARCEL ID: , v�,�,
STREET ADDRESS: � � � � i 0.� �.Ni IC. � �� !� I � �� � _
,�� � dq � ,�1 ° , � y� -
Please print: � � O'T'
Properly Owner: �
Properly Owner:
The undersigned, registered properly owners of the above noted property, do hereby authorize
.��.'./1 �GC /' ✓' . of ��� �/1 � �l L°.� r ►✓I �i� C ,
(Contractor / Agent) (Name of c�nsulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
ti�is permit or certificatfon and any and all standard and special conditions attached.
Property Owner's Address (if difFerent than properly above):
� a S o��a� �*� S , er �� �/� ��315�
Telephone: / � � � / � � r � 3 I �1
We hereby certify the above informatlon submitted in this application is true and accurate to the
best of our knowledge.
�� �
Authorized Signature Authorized Signature
Date: c� '�'.�/� �'/� Date: