20241379 Ver 1_Agent Authorization (2)_20241010

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. _ PLAN N0. _ PARCEL ID: 8-013-191
STREET ADDRESS: _901 Char:man St. New Bern. NC 28560
Please print:
Property Owner: —CiFv of New Bern: NC
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Dawn York
(Contractor / Agent)
of __Moffatt & Nichol
(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): 300 Pollock Street. New Bern; NC
28563
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
_4� H-,-
Authorized Signature Authorized Signature
Date:_ `(" S —a t. a Date: