20260001A_authofagent.pdf
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- Attached to
- XUMU 20260001A Bldg 15501 FOC Comm Install
- Solicitation number
- FA461026Q0040
About this file
This is an Authorization of Agent form for the California Department of Transportation Encroachment Permit Office located in San Luis Obispo.
The form permits a property owner or legal representative (Permit Applicant) to authorize an agent to apply for and act on their behalf in submitting a State of California Department of Transportation Encroachment Permit. The Permit Applicant must acknowledge that they have reviewed the Standard Encroachment Permit Application Form and agree to its terms and conditions. The form requires completion of three main sections: Property Information, Encroachment Location, or Description (including property address, state route number, city or county, and additional reference information); Permit Applicant Information (name, street address, city/state/zip code, phone number, signature, title, and date); and Agent Information (name, firm name, street address, city/state/zip code, phone number, signature, and date). Both the Permit Applicant and the authorized agent must sign and date the form. This is a template form with blank fields for data entry and does not specify particular products, services, or contract terms.
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Text version
STATE OF CALIFORNIA - CALIFORNIA STATE TRANSPORTATION AGENCY EDMUND G. BROWN Jr., Governor
DEPARTMENT OF TRANSPORTATION
ENCROACHMENT PERMIT OFFICE
50 HIGUERA STREET
SAN LUIS OBISPO, CA 93401-5415
PHONE (805) 549-3152
FAX (805) 549-3062
TTY 711
http://www.dot.ca.gov/dist05
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AUTHORIZATION OF AGENT
I, the owner as the Permit Applicant or legal representative for the Permit Applicant identified below, hereby authorize my agent, listed below, to apply for a State of California Department of Transportation
Encroachment Permit and act on my behalf. In completing and signing this form I acknowledge that I have reviewed the State of California Department of Transportation Standard Encroachment Permit
Application Form and agree to its terms and conditions.
Property Information, Encroachment Location, or Description
Property Address or
Facility Description:
State Route Number:
City or County:
Additional Information:
(Project Reference No., APN, Tract Number, Subdivision Name, etc.)
Permit Applicant Information:
Name:
Street Address:
City, State, Zip Code:
Phone Number:
Print Name:
Signature:
Title:
(Owner, Partner, Corporation Officer, Specify Other)
Date:
Agent Information:
Name:
Firm Name:
Street Address:
City, State, Zip Code:
Phone Number:
Print Name:
Signature of Agent:
Date:
http://www.dot.ca.gov/dist05
File details come from the government source that posted it. Updated .