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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 />Notarized Affidavit of Signature <br />STATE OF: ) <br />COUNTY OF: 1 ss <br />The foregoing instrument was acknowledged <br />before me this day of by <br />(date) (year) <br />as <br />(Name of permittee representative) <br />(seal) <br />My Commission expires: <br />of <br />(title) <br />(permittee) <br />Page 3 of 4 <br />NOTARY PUBLIC <br />