- 12/2/2022 4:53 PM

EXAMPLE AGENT Ail T HORiZATION FORMI `. .
Proaerw Legal Descrialon:
020417
Parcel ID.
1330
Lot No. (if applicable) —_Plan No. (if applicable)
241 Sagamore
Street Address(ff apPlacacie;' Dr .
z; onerw Finer.
Duane and Mary Drinkwine
Owner ltlarne (print):
propeee}r e)rvner s Address (if different than the above?:
642 FOSTER LANE Pittsboro, NC 27312
Owner Signature:
The above registered property owners ofthe above properly, do hereby authorize
Phil Poland Phil's quality construction
of
Agent ma -me Agent Company Name (ifappli-able}
to act on tray Behalf and take all actions neces ary for the application, processing, issuance and
ascept_.nce of -this permit, cerdfication or authorization including all standard and special conditions
attached.
I hereby certify that the above information submitted on this form and apprication is true and accurate
to tide k:st of ar•,r F.nowl edge. (� I 1/�
Authorized agent Name / Company: � 1�ti�) 1'/1 \ A / I� h, � S � 1 � 1I ,
� n S C-4,
Autha ;zed Agent Signature'.
Date: