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Agreement to Conduct Permitting by Electronic Means d DEC , <br /> DN/StoN of ?�17 <br /> REr�a nr r MI(yly�.�<�P,-�,�1 • .a;/{fit <br /> Name of permittee representative desiring to (- <br /> opt in to ePermit: e-aJN t S C '1 IU-e I J LO(L <br /> Title: <br /> Name of permittee: <br /> Signature: <br /> ePermitting Administrator(if different from <br /> representative signing agreement) <br /> Email Address for ePermit Account: r4i y N e <br /> OJ p,5 .9'►i d.l�,. r o�s'L <br /> Notarized Affidavit of Signature <br /> STATE OF: ) <br /> o�� <br /> COUNTY OF: C� ) ss. <br /> The foregoing instrument was acknowledged <br /> before me this )2- day of by <br /> (date) (month) year) <br /> bb,n i1Pi e4l as �L)V-A-- <br /> (Name of permittee representative) (title) <br /> of <br /> fher�)i . N - U—L <br /> (permittee) <br /> KIMBF-RLY D. BLOSSOM <br /> NOTARY FJBLIC f/J <br /> S i ATE OF COLORADO �C <br /> NOYARY I 20064016248 <br /> MYuOMIVIISSIQN EXPIRES APRIL26,2018 I�OTARYP LIC <br /> (seal) <br /> My Commission expires: 0 q)-Y,bp q <br /> Page 3 of 6 <br />