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Agreement to Conduct Permitting by Electronic Means <br /> Name of pennittee representative desiring to <br /> opt in to ePennit: <br /> Name of pennittee: <br /> Title: <br /> Signature: _. <br /> Email Address for ePennit Account: <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this ZS day of 3CLv%ua- 20ib by <br /> (date) (year) <br /> as <br /> (Name of pennittee representative) (title) <br /> of <br /> ur1 v►� �n.c, V�I� l� q,���-e r� <br /> (pennittee s-sOc i IA A-io.A) <br /> q05ARY PU IC <br /> BONNIE JAY GLOVER <br /> NOTARY PUBLIC <br /> STATE(seal) NOTARY ID 334003 949 <br /> My Commission expires: 14comff&" pdoW29'2019 <br /> Page 3 of 4 <br />