2023-02-08_REVISION - M2003016 ‎(2)‎

• Permit No: M2003016
• IBM Index Class Name: Revision
• Doc Date: 2/8/2023
• Doc Name: Request For Succession Of Operator
• From: City and County of Broomfield
• To: DRMS
• Type & Sequence: SO4
• Email Name: ECS
• Email Name: MAC
• Email Name: SMS
• Email Name: AWA
• Media Type: D
• Archive: No

NOTARY FOR STRUCTURE OWNER
ACKNOWLEGED BY:
Structure Owner Name
Date Title
STATE OF _ )
ss.
COUNTY
The foregoing was acknowledged before me this_____ day of _ _ _ , 20_._ by
as of
___ My Commission Expires:
Notary Public