AGENT AUTHORIZATION FORM
Property Description:
Address:
City: ___________________________ Postal Code: ___________________________
Please print:
Registered Property Owner:
Registered Property Owner:
Telephone: __________________ Email: _____________________________________
The undersigned, registered property owners of the above noted property, do hereby
authorize:
, of
(Contractor / Agent) (Name of firm)
Address: _______________________________________________________________
Telephone: _______________________ Email: _______________________________
to act on my behalf and take all actions necessary for the processing, issuance and
acceptance of this permit and any and all standard and special conditions attached.
Property Owner’s Address (if different than property above):
We hereby certify the above information submitted in this application is true and
accurate to the best of our knowledge.
Authorized Signature Authorized Signature
Date:__________________________ Date:
________________________________ __________________________________
Witness Name Witness Signature
Date: ___________________________
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signature
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