20230803 Ver 1_Jacobs Creek_AGENT_AUTHORIZATION_FORM_20230605

Three Oaks Engineering, Inc
324 Blackwell St, Suite 1200
Durham, NC 27701
AGENT AUTHORIZATION FORM
792201050275,
PROPERTY LEGAL DESCRIPTION: 792201255899,
792202767238,
LOT NO. PLAN NO. PARCEL ID: 792204840294
STREET ADDRESS: Jacob's Creek Residential Development
313 Bennett Farm Rd, Stokesdale, NC 27357
Please print: LG I Homes
Property Owner:
Property Owner:
ATTN: Josh Spiegel
The undersigned, registered property owners of the above noted property, do hereby authorize
Jim Mason
(Contractor / Agent)
of Three Oaks Engineering, Inc.
(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):
5511 Capital Center Dr, Suite 560, Raleigh, NC 27606
Telephone:
980-722-0391
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
thorized Signature
Date: 5.30.2023
Electronically signed by:
Authorized Signature
Date: 5/27/2023