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Agreement to Conduct Permitting by Electronic Means <br /> Name of permittee representative desiring to rr�� <br /> opt in to ePermit: <br /> Name of permittee: � <br /> Title: , h,-Lc- <br /> Signature: <br /> Email Address for ePermit Account: EpL1 Vq-(IE$ GjCC _ corn <br /> Notarized Affidavit of Signature <br /> STATE OF: C p iora dp ) <br /> COUNTY OF: PU e—6 1 o ) ss. <br /> The foregoing instrument was acknowledged -/�before me this 2�o— day of A Q 2-0/6 by <br /> _ (date) (year) <br /> — �clw +) �livt�reS as <br /> r /:—En✓,"ro,,,men F oecrr <br /> (Name of permittee representative) (title) <br /> of <br /> GCC �-lQ C7rGnCle, ZhC <br /> (permittee) <br /> JACKISERNA NOT Y PUBLIC <br /> Notary Public <br /> State of Colorado <br /> Notary ID 20144042744 <br /> ommission Expires Nov 4, 2018 <br /> (seal) <br /> My Commission expires: <br /> Page 3 of 4 <br />