20080760 Ver 3_Agent Authorization_20230530

AGENT AUTHORIZATION FORM
Please note that multiple forms may be necessary if there are more than two owners of the property.
PROPERTY LEGAL DESCRIPTION:
STREET ADDRESS OF EXISTING HOME or LATITUDE/LONGITUDE OF NEW CONSTRUCTION:
4522 Ayden Golf Club Road, Ayden, NC 38513
Parcel ID: Pitt Co. Parcel #77031
Property Owner Name(s)—please print:
Property owner: Garris-Evans Lumber Company
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
J. Dwight Vernelson of Rivers & Assoc., Inc.
(Contractor/Agent) (Name of company)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of this
permit or certification and any and all standard and special conditions attached.
Property Owners Mailing Address (if different than property address above):
701 W. 14th Street, Greenville, NC 27834
Property Owner(s) Telephone: [phone]
We hereby certify that the above information submitted in this application is true and accurate to the
best of our knowledge.
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Au rized Si nature Authorized Signature
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Date Date