Laserfiche WebLink
Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to/j <br />opt in to ePermit: �1� !•-t � r 2 �- <br />Title: V, 0 �� S <br />Name of permittee: <br />Signature: A.J <br />ePermitting Administrator (if different from <br />representative signing agreement) <br />Email Address for ePermit Account: UD 0. T4 S atd <br />. <br />Notarized Affidavit of Signature <br />STATE OF: <br />COUNTY OF: <br />Elm t~&P, <br />The foregoing instrument was acknowledged <br />before me this I day of <br />(date) <br />ss. <br />fPQG , by <br />(month) (year) <br />24 " 46 asy 9 gi a PLraaex d <br />(Name of pe mittee representative) (title) <br />of <br />NOT=3�34 <br />STATE MIW;40 <br />NOTARY <br />MY SO <br />(seal) <br />My Commission expires: <br />k5WIZ-5.0 -T— I LLe—, <br />(permittee) <br />Page 3 of 6 <br />NOTARY PUBIVC <br />