COUNTY OF DUFFERIN
BUILDING DEPARTMENT
AGENT AUTHORIZATION FORM
TOWN or TOWNSHIP: ____________________________________________
Legal Description: Lot: ____________ Plan/Conc: ________________
Street Address: __________________________________
The undersigned, registered property owner(s) of the above noted property, do hereby
authorize _________________________________________, to make applications and amendments to
applications on our behalf. It is understood that we will abide by all by-laws and acts of
the County of Dufferin and that any approvals granted by this application will be
carried out in accordance with the municipal requirements.
Property Owner’s Signature: _______________________________________
Print Name: ___________________________________
_____
Date: _______________________________
Property Owner’s Address (if different than property above):
Telephone: _______________________________
