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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: <br />Name of permittee - <br />Signature: <br />ePermitting Administrator (if different from <br />representative signing agreement) <br />Email Address for ePermit Account: <br />Jar &TRIC e ok/ <br />/0WS.1'0zVT- <br />J 11 S"X-Ve-1-1d9iAl- .vF wv��sskx l�rc, <br />Notarized Affidavit of Signature <br />STATE OF: } <br />COUNTY OF. } ss. <br />The foregoing instrument was acknowledged day <br />of 0� by <br />before me this 0 <br />(date) (month) (year) <br />as <br />� OC ges I I'l t <br />(Name of permittee rep s tative) (title) <br />ASHLEY TOBIAS <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY 10 20174029217 <br />MY COMMISSION EXPIRES JULY 12, 2021 <br />(seal) <br />My ComrnL-;sion expires: <br />of <br />(permittee) <br />Page 3 of 6 <br />NOTARY PU LIC <br />