Laserfiche WebLink
RECEIVE <br /> J Agreement to Conduct Permitting by Electronic Means <br /> JUN 0 2 2016 <br /> DIVISION OF REC1AMATLOt <br /> Name of permittee representative desiring to kQ <br /> MI aMFSopt in to ePermit: /v`I c 61, vt <br /> Title: Pre <br /> 42A- +- <br /> Name of permittee: G ` <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: S po c i ttieio/ 1,,, p p co f -(o0/l <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> Colorado <br /> COUNTY OF: ) ss. <br /> 2rt vrr- <br /> The foregoing instrument was acknowledged <br /> before me this • -rtI- day of , 4 by <br /> (date) (month) (year) <br /> as <br /> Kikea( O. :Ton.e5 I�reS iyl t <br /> (Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> BARBARA J.CORIA4114/,--41-4 6 <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19974013343 NOTARY PUBLIC <br /> MY COMMISSION EXPIRES JULY 25,2017 <br /> (seal) <br /> My Commission expires: <br /> -7 72 / -077 <br /> Page 3 of 6 <br />