Form Builder

Required fields are marked with asterisks (*)

Temporary Burlington Housing Community Improvement Plan Program

Agent Authorization Form

Registered Owner(s)

Address of the subject property:

I/we, the registered owner(s) of the Property, authorize the below name Applicant to apply for the Temporary Burlington Housing Community Improvement Plan Program on my/our behalf. I/We authorize the Applicant to be the principal contact with the City of Burlington for this application.

Name of Registered Property Owner

Property Owner Signature

Clear

Date of Signature:

Add additional Owner Remove

Authorized Agent Information

Name of the Agent

Company Name

Unit:

Address:

City:

Province:

Postal code:

Primary phone number:

Agent email address:

Notice of Collection

The personal information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. M.56, Municipal Act 2001, S.O. 2001, c. 25 and/or the Building Code Act, 1992 S.O. 1992, c. 23. The information will be used for the purposes of assessing your application against the CIP program requirements. Questions about this collection can be directed to the Manager of Policy & Regulatory Services, 426 Brant Street, Burlington, Ontario L7R 3Z6, 905-335-7731, engpermitrequests@burlington.ca.

Owner(s) if you wish to received a copy of your Agent Authorization letter please enter your email: