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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF

PLANNING AND NATURAL RESOURCES DEVELOPMENT PERMIT APPLICATION



FORM L&WD-5

PROOF OF LEGAL INTEREST



AFFIDAVIT



3) ‘i

I, Jo coc A Dot Qek (L\\wet tame \ve_ O SUI ue being duly sworn depose and say that:

S Appliddnt(s)* {or John Doe of Entity Applicant)



Lope ska WO Ve USUI Tic amis the (check one)



(L arEntity/Applicant)



Dlessee [JOther (specify) | _|



CO Record title owner (fee simple)



Of the real property described as Parcel No(s)___C2 > q- |

Quarter Coral “pans Island + a 5 as son



ocumentation for legal interest stated above (e.g. deed, lease,



Estate Cato Wn



*Applicant(s) is required to provide d

etc.)



ey from all other persons with a legal interest



2. [have the irrevocable approvals, permission, or power of attorn

fully set forth in the exhibit



in the property to undertake the work proposed in the permit application as more

(s) attached hereto:



asa

Signaturg—— Date Signature Date



Jota A2Wotoet ie Bivalt \\o

Print



Print



The foregoing instrument was acknowledged before me this day of



> »b Worcs. Ke Maioe Moly le > c Op. at Som QVav county

a0 = ¥ (Name or e/Title of Entity)



of PUL RNCO we ‘S



os 7

My Commission expires



Notary Public