2017-05-18_REVISION - P2009018

• Permit No: P2009018
• IBM Index Class Name: REVISION
• Doc Date: 5/18/2017
• Doc Name: Returned Mail
• From: DRMS
• To: Marcie Jaeger
• Email Name: LJW
• Media Type: D
• Archive: No

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