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Agreement to Conduct Permitting by Electronic Means <br /> Name of permittee representative desiring to I ,, <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 Affidavit of Signature <br /> STATE OF: ( ) <br /> COUNTY OF: � ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this ? day of 20► by <br /> (date) ( onth) (year) <br /> rr ` as nn n <br /> (Name of permittee represe t tive) (title) <br /> of <br /> (permittee) <br /> AV MI <br /> BO NOTARY PUBLICppp OTARY PU LIC <br /> STATE Cr C 003403694919 <br /> ��anT s�Yon�Expires 2 <br /> (seal) <br /> My Commission expires: <br /> 2 t7 cA"Zvr <br /> Page 3 of 6 <br />