20201968 Ver 2_Agent Authorization_20210930

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. N/A —PLAN NO. N A PARCEL ID: 165492 1636894
STREET ADDRESS: _N/A: ROW for US HWY 221 off parcels 165492 and 1636894
Property Owner: NC DOT Representative- Christopher A. Guffey (District Engineer)
The undersigned, registered property owners of the above noted property, do hereby authorize
Adam Williams of Brushy Fork Environmental Consulting, Inc.
(Contractor/Agent) (Consulting Firm)
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 Owner's Address (if different than property above):
3931 NC HWY 226 S Marion NC 28752
Telephone: [phone]
We hereby c ify the above information submitted in this application is true and accurate to
the b t ur knowledge.
rized Signature:
Date: -� �P�'ylc��•� �OZ./