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DEPARTMENT OF PLANNING AND BUILDING <br /> o .-. 18 61 A DEPARTMENT OF PUBLIC HEALTH AND ENVIRONNMENT <br /> 1555 NORTH 17TH AVENUE <br /> GREELEY, CO 80631 <br /> AUTHORIZATION FORM <br /> 1, (We), A Fak,I/ give permission to ic�PS I/C &(el/ jca(SPyrJ/G� <br /> (Ownej please pr'n (Authorized Agent-pl6Ase print) <br /> to apply for any Planning, Building or Septic permits on our behalf, for the property located at (address or <br /> parcel number) below: <br /> Legal Description:50(4A Aal't of Section-3y , Township 5 N, Range( 6 W <br /> Subdivision Name: Lot Block <br /> Property Owners Information:Address: Alle-1q . pQ Oox SoS C ellowskhe R14 w(l, $Zl lq <br /> b <br /> Phone: 30 -341q' 25 6 E-mail:lod'- al�e� <br /> Authorized Agent Contact Information: <br /> Address: A /fby T ,✓ ( <br /> • Fd tl 2 <br /> Phone: Zd q6"D 342- E-Mail: G /rl Dq—, we-4'il'IrC. . c�orvl <br /> Correspondence to be sent to: Owner Authorized Agent C� Both / by Mail Email <br /> Additional Info: 6OA)8PL P 0/297-55 ' JC) <br /> / -7 , 06 PZIoS <br /> , Co <br /> Owner Signature: Date: <br /> Owner Signature: �--- /f Date:_ _7 1 I r ' 7 D/� <br />