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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: hI? <br /> Name of permittee: T' <br /> Signature: " <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: Q rnS� <br /> Notarized Affidavit of Signature_ <br /> STATE OF: ) <br /> nlLYGldo <br /> COUNTY OF: ) ss. <br /> �U <br /> The foregoing inst ment was acknowledged <br /> before me this =�_ day of ,.1 S'� , by <br /> (date) (m h) (year) <br /> as <br /> 01A. nPv- <br /> (Name of permittee representative) (title) <br /> of <br /> F <br /> ?ASHA JENNIFER GOh4 G (pe i tee) <br /> Notary Public <br /> State of Colorado <br /> Notary 10 0 20164012903 <br /> C mis4ioe E s 04- ��Y01! <br /> NO Y��UBLIC <br /> (seal) <br /> My Commission expires: 1.,I 1 ok <br /> Page 3 of 6 <br />