20230759 Ver 1_Agent Authorization_20230601

AGENT AUTHORIZATION FORM
Please note that multiple forms may be necessary if there are more than two owners of the property.
STREET ADDRESS OF EXISTING HOME or LATITUDE/LONGITUDE OF NEW CONSTRUCTION:
105 Beacon Ridge -Dr. Connelly Sprinqs, NC 28612
35.779/-81.512
Property Owner Name(s) — please print:
Property Owner: Robert Clark
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Charlie Washburn
(contractor/Agent)
,of Marine Construction LLC
(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):
7698 Red Robin TO. Denver, NC 28037
7698 Red Robin Trl. Denver, NC 28037
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.
Authorized Signc7ture
----,5 - 2-3
Date
Authorized Signature
- 5-25-A3
Date