20190428 Ver 1_More Info Received_20190409

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION: PIN'
LOT N0, PLAN NO, PARCEL ID:
STREET ADDRESS: 1%�,� T� t
oC
Please print:
Property Owner: Do row rr i s
Property Owner: 1
The undersigned, registered property owners of the above noted property, do hereby authorize
_Wbr ojc�, of
(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):
q
Telephone: C 1�`r 0
`I
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Av2aW A
Authorizedignature Authorized Signature
Date: Q..H / Q ( /101 Date: