20221501 Ver 1_R-2588B_agent authorization form_20221024

DocuSign Envelope ID: ED6344AB-3686-44E2-9BD2-05254BBBF9C7
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
STREET ADDRESS: NCDOT TIP R-2588B NC 191 from NC 280 to Mountain Rd (SR 1381)
Please print: NCDOT Highway Division 14 (Wanda H. Austin, Kevin Barnett)
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
David B. Petty
(Contractor / Agent)
of TGS Engineers
(Name of 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):
253 Webster Road, Sylva, NC 28779
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
DocuSigned by:: - ll
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Authorized Signature
10/24/2022 1 3:32 PM EDT
Date:
Authorized Signature
Date: