ch information provided herein, is true, complete and accurate. I further cenify that I possess the authority to undertake the proposed activities. Signature of Applicant or Agent Signature of Owner (Where Applicant or AgriRis not er) Date FOR DEPARTMENT USE ONLY Inspector Record Date Inspected: ( )Permit App

h information provided herein, is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activities. Signature of Applicant or Agent Date Signature of Owner (Where Applicant or Agent is not Owner) FOR DEPARTMENT USE ONLY Inspector Record Date Inspected: ( )Permit

h information provided herein, is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activities. Signature of Applicant or Agent Signature of Owner (Where Applicant or AgSttf is not er) FOR DEPARTMENT USE ONLY Inspector Record Date Inspected: ( )Permit Approve

h information provided herein, is true, complete and accurate. I further certify that I possess the authority to undertake the proposed activities. Signature of Applicant or Agent (if not owner) Date Sign Print Sign Owner(s) (Rquiredr--- Date ) Criltk I fin J1) 4-4 n olgo-to f I to k tr./ Print S St I,- t