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DEPARTMENTS OF PLANNING <br /> # 1861a � BUILDING, DEVELOPMENT REVIEW <br /> AND ENVIRONMENTAL HEALTH <br /> 1555 NORTH 17TH AVENUE <br /> GREELEY, CO 80631 <br /> Qa�, / I�u� � AUTHORIZATION FORM <br /> I, (We), a,,r give permission to -s <br /> (Owner-please print) (Authorized Agent/Applicant-please print) <br /> to apply for any Planning, Building, Access or OWTS permits on our behalf, for the property located at <br /> (address or parcel number)below: <br /> PAR-aL'9 /0_S <br /> Legal Description: of Section Z/ Township VA) N, Range i�c-)- W <br /> Subdivision Name: Lot Block <br /> Property Owners Information: <br /> Address: I gY60 C/3 �O P�a flev,l�G' Co <br /> Phone: Lo-- 3'I -U q/7 E-mail: <br /> Authorized Agent/Applicant Contact Information: <br /> Address: �U S (�✓.�yiV�/xj G% (�/f/27 /�'��� /�aA-r �'QccT_i✓` �dv�.Zs <br /> Phone: 9526 2/ 9 ,3 %`6 E-Mail: SLC(�/V�QS�Gc�tiT/L/�GTZ�+/�. CO1"t <br /> Correspondence to be sent to: Owner \/� Authorized Agent/Applicant by: Mail Email <br /> Additional Info: <br /> I (We) hereby certify, under penalty of perjury and after carefully reading the entire contents of this <br /> document,that the information stated above is true and correct to the best of my(our) knowledge. <br /> Date 1y�l�'i;�? L�� �Date <br /> Owner Signature Owner Signature <br /> Subscribed and sworn to before me this o2U day of 20 by <br /> My commission expires <br /> Y PUBLIC <br /> Nota PNk ,ID 00094000087*7 <br /> MY COMMISSION EXPIRES MARCH 12,2025 <br />