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Agreement to Conduct Permitting by Electronic Means <br /> X--90�e� 14'emH.41"1 foie : <br /> Name of permittee representative desiring to ; <br /> opt in to ePermit: <br /> Title: sly <br /> Name of permittee: <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: -aAa!Yt-(6) l i�(-,Q�t n n rn <br /> t CJI� <br /> Notarized Affidavit of Si ng ature ��y� <br /> STATE OF: le l ',j tic <br /> 20 <br /> �i <br /> COUNTY OF: ) ss. 4sMING'�� <br /> The foregoing instrument was acknowledged <br /> before me this day of by <br /> (date) �, (month) (year) <br /> as VIL 2�k�14 'k�(Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> r <br /> /NOfARY PUBLIC <br /> (seal) <br /> My Commission expires: ` <br /> �h <br /> Page 3 of 6 <br />