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Agreement to Conduct Permitting by Electronic Means <br /> Name of permittee representative desiring to <br /> opt in to ePermit: <br /> Title: <br /> Name of permittee: <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> COUNTY OF: ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this day of by <br /> (date) (month) (year) <br /> as <br /> (Name of permittee representative) (title) <br /> of <br /> (permittee) <br /> NOTARY PUBLIC <br /> (seal) <br /> My Commission expires: <br /> Page 3 of 6 <br />