Laserfiche WebLink
greement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt in to ePermit: <br />Title: <br />Name of permittee: <br />Signature: <br />ePermitting Administrator (if different from <br />representative signing agreement) <br />Email Address for ePermit Account: <br />STATE OF: <br />COUNTY OF: <br />ECrEW" <br />APR 0 7 2010 <br />DivisoN OF RECLAMATION <br />MINING AND <br />/I/4fv.4-4, r16,- ,nii € <br />"ffee- G . SCIC'yt , Ci)/1.1# C Vc/li (�! C'_ <br />Notarized Affidavit of Signature <br />C0 v dO <br />6.O CL. Icy <br />The foregoing instrument was acknowledged <br />before me this <br />(Name of permittee represents ive) <br />WENDIE M ELLIOTT <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 1 20064042200 <br />MY COMMISSION EXPIRES OCTOBER 16. 2018 <br />(seal) <br />My Commission expires: <br />1 TJ <br />Ib <br />D -C <br />ss. <br />.5 ' day of <br />(date) (month) <br />as <br />(title) <br />of <br />(permittee) <br />by <br />(year) <br />411 <br />GUQ,n m EJ <br />Page 3 of 6 <br />NOTARY PUBLIC <br />