Ver _NC1 146 - Agent Form signed_20240722

Docusign Envelope ID: 82D9CB42-19CF-4582-92A0-E8FACC0806BA
SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. n/a PLAN NO. PARCEL ID: 0821474147
STREET ADDRESS: 1121 Jackson Street, Durham NC
Please print:
Property Owner: Mogahid Elzubir
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
James Rumley of Caruso Homes On Your Lot NCI, LLC
(Contractor / Agent) (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):
301 Ridgestone Parkway, Durham, NC 27712
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
DocuSigned by:
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Authorized Signature Authorized Signature
7/13/2024
Date: Date: