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• Agreement to Conduct Permitting by Electronic Means <br /> A <br /> Name of permittee representative desiring to _ <br /> opt in to ePermit: X \ Q L\Q. C�\ <br /> Name of permittee: <br /> \13 �o�cdGC� <br /> Title: ( Sc <br /> YZIYYI 1� vil 5\t‘ Q.0 V \SC`r'C <br /> Signature: <br /> Email Address for ePermit Account: <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> 612e-0R/460 <br /> ?/1f D <br /> COUNTY OF: ) ss. <br /> i» /4S <br /> The foregoing instrument was acknowledged <br /> before me this j/ day of/f'j 2.0 by <br /> (date) (year) <br /> as <br /> (Name of permittee representative) (title) <br /> of <br /> fkyp6, <br /> ��' Q;• •;�,,, (permittee) <br /> 2' r'AULINE <br /> HERBERT. aI • <br /> Nle•'•. 0 <br /> 00=9� ` ,..__... �`�°���� NOTARY PUBLIC , <br /> FXPIRO <br /> (seal) <br /> My Commission expires: <br /> Jv2(J �, 26/6 <br /> Page 3 of 4 <br />