20181737 Ver 2_PNG_Line448_449_AGENT_AUTHORIZATION_FORM_TEM_20190730

AGENT AUTHORIZATION FORM

PROPERTY LEGAL DESCRIPTION:

LOT NO. ______________ PLAN NO. ____________ PARCEL ID: ________________________

STREET ADDRESS: _____________________________________________________________

_____________________________________________________

Please print:
Applicant: ________________________________________________________________

Contact: ________________________________________________________________

The undersigned, registered property owners of the above noted property, do hereby authorize

__________________________________, 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.

Applicant 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.

__________________ __________________
Authorized Signature

Date: _______________________________