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C) Agreement to Conduct Permitting by Electronic Means <br /> ` �Oo�-- ° ' <br /> Name of permittee representative desiring to <br /> opt in to ePermit: - <br /> Title: �C'C <br /> ` i-;1"'- <br /> Name of permittee: P , <br /> L7_ <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) NICU k l�/QJ"�7►�l <br /> Email Address for ePermit Account: <br /> h?Mar hn CaD ape. US. CCni <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> c� d <br /> COUNTY OF: ) ss. <br /> The foregoing inst me as acknowledged <br /> before me this f day of by <br /> (date) (month) (year) <br /> as <br /> (Name of pe ittee repr s tative) (title) <br /> of <br /> (permi ee) <br /> CAROL WRIGHT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20094040322 <br /> MY COMMISSION EXPIRES DECEMBER 09,2077 <br /> TARY UBLIC <br /> (seal) <br /> My Commission expires: <br /> l� - q , zoc7 <br /> Page 3 of 6 <br />