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Agreement to Conduct Permilling by Electronic lbleans <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 />' <br />71 <br />1 <br />I <br />Notarized Affidavit of Signature <br />STATE OF: � zme D ) <br />COUNTY OF: xlql�f ) <br />theforegoinginstrumerit as acknowledged <br />before me this I�T� <br />(date) <br />ss. <br />(Name of permittee representative) <br />JESSICA BARRETT <br />Notary Public <br />State of Colorado <br />Notary ID # 20054014807 <br />My Commission Expires 05.24-2021 <br />(seal) <br />My Commission expires: <br />day of I&& <br />, �7 by <br />( onth) (year) <br />as r �� <br />(title) <br />of <br />D , <br />(permittee) <br />rTXRY PUBLIC <br />mem <br />Page 3 of 6 <br />