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1 <br />Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt in to ePermit: <br />Name of permittee: <br />Title: <br />Signature: <br />Email Address for ePermit Account: <br />STATE OF: <br />Cthratio <br />COUNTY OF: <br />',IAN i 1 tti16 <br />DMS1ONOF REQ./MATO <br />We./ <br />!/), rj <br />rvi el ; /G rk✓, <br />Notarized Affidavit of Signature <br />Pf -rS <br />The foregoing instrument was acknowledged <br />before me this <br />attu,tkt1 <br />LOLL <br />ss. <br />11' <br />(Name of pa ittee representative) <br />1 <br />ELIZABETH M MASON <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID N 19974012157 <br />MY COMMISSION EXPtRD JULY OS. 2017 <br />(seal) <br />My Commission expires: <br />V3D0t7 <br />(date) <br />as <br />of <br />day of 20 by <br />(year) <br />P. CSS na-1 I toul U ? et)&i <br />(title) <br />U. -1,H kmtr. <br />(permittde) <br />Page 3 of 4 <br />NARY PUBLIC <br />