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Agreement to Conduct Permitting by Electronic Means <br />Name of permittee representative desiring to <br />opt in to ePermit: (10,:Ct�mo" $, Lkl,(�L <br />Name of permittee: <br />Title: <br />Signature: <br />Email Address for ePermit Account: <br />�CL�non�/�� rn4� 1 • �rn <br />Notarized Affidavit of Signature <br />STATE OF: } <br />COUNTY OF: ) ss. <br />The foregoing instrument was acknowledged <br />before me this a M <br />(date) <br />day of 17 <br />(year) <br />60A=m sun QMlt" tgtjw�L.— as <br />P.A.A. <br />(Name of permit ee representative) (title) <br />of <br />(seal) <br />My Commission expires: <br />(permittee) <br />Page 3 of 4 <br />F�TT-PUBLIC <br />JOHNIE ABAD <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20084020977 <br />MY COMMISSION EXPIRES JUNE 18 2020 <br />