20181385 Ver 1_More Info Received_20181212

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SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.. PARCEL ID:
STREET ADDRESS:' �f �� Lo C Z� : S� Nis=ic, X. G
—2-73q 3
Please print: A M �' n I
Properly Owner: DG 11 i N �� e��
'Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
L . L � 1.�, 5 , of � �l J � � `b S u vz s
(Contractor / Agent) .(Name of c nsulting 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:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
f
uthariz, ignature / Authorized Signature
Date: /f `z Date: