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Agreement to Conduct Permitting by Electronic Means <br /> Name ofpermittee representative desiring to <br /> opt in to ePermit: 11,A a P <br /> Title: <br /> �utitc�Cj'!i <br /> Name of permittee: <br /> wG-a� dzrSctArC(f 5S <br /> 141 <br /> Signature: j J <br /> r <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: r��h��(o,15��e. �• ti S <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> L6�C.UI�!)Ua <br /> COUNTY OF: ) ss. <br /> GN tGZu�t A <br /> The foregoing instrument was acknowledged <br /> before me this day of ,g , Xt)I,Z by <br /> (date) (month) (year) <br /> as <br /> �re llllCl 71lvHp�a.-rJ A AA)69.12- <br /> (Name ofpermittee representative) (title) <br /> of <br /> e-1 1-Pe za /l'1 cNL ki�G l���du�'LGS L L G <br /> MARY DEWEESE (permittee) <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20084036833r <br /> MY COMM.EXPIRES NOVEMBER 13,2= NOTARY/PUBLIC <br /> (seal) <br /> My Commission expires: <br /> Page 3 of 6 <br />