NCC223328_FRO Submitted (2)_20220922

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CHATHAl11 COUNTY
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CHATHAM COUNTY
AUTHORIZED AGENT FOR FORA
PROPERTY LEGAL DESCRIPTION:
LOT NO. PARCEL ID (PIN) 9131 PARCEL SIZE 1.63
STREET ADDRESS: 20 Cypress Ln., Goldston, NC 27252
Please print:
Prop"- Owner- Thomas R. Kirk, II
Propert}. Owner Andrea P. Kirk
The undersigned o%vner(s) of the above described property, do hereby authorize
Josh Brooks
(Contractor / Agent)
, o fJB Builders, LLC
(Name of consulting firm if applicable)
to act on my/our behalf and take all actions, Uwe could have taken if present, necessary for the processing, issuance
and acceptance of reviews, inspections, or permits and any and all standard and special conditions attached to
these approvals. The activities authorized include the following (Check all that apply):
R1Check here for all of the below options.
--�❑.T Building Permit
_J__i__ Zoning Compliance Permits
Floodplain Determination
[]_ Soil Erosion & Sedimentation Control Permit
❑ Permits to install, repair, evaluate, or expand onsite wastewater system(s)
Evaluation'inspection/permitting of a private drinking water well(s).
j:]_ Riparian Buffer Review pursuant to §304 of the Chatham Co. Watershed Protection Ordinance.
=Other: Submit EC plan and complete anticipated land disturbing activity
Property Owner's Address (if different than property above):
P.O. Box 367, Goldston, NC 27252
Telephone: [phone] E-mail: alpkirk@gmail corn
P
cby certify the above information s bmitted in this application is true and accurate to the best of our
dge.
Authorized Signature 1,/ Agen u1hori7/15/2022 Dalc: 911 W022
Revised 1/2022