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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 />COUNTY OF: <br />( .4a.194 t? Pie <br />\ nes 60 <br />OuAer- <br />l� <br />I?t'0/ela/1a/S07is@ lC nr20 ( <br />Notarized Affidavit of Signature <br />The foregoing instrument was acknowledged <br />before me this <br />of permittee rere�t <br />) ss. <br />p ative) <br />SHIRLEY L WITHERSPOON <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />4 <br />NOTARY ID 19914001387 <br />MY COMMISSION EXPIRES MARCH 7, 2019 <br />(seal) <br />My Commission expires: <br />,3//2r/9 <br />/9 <br />day of <br />(date) (year) <br />as <br />(title) /) <br />of ��'�r�'i /� / <br />by <br />rmittee) <br />Page 3 of 4 <br />4 21:66,,,L#7,) <br />NOTARY PUBLIC <br />