20190513 Ver 1_More Info Received_20190513

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 58 PLAN NO. _ PARCEL ID:
STREET ADDRESS: 23$ �)k��V1E-xo �� CORY NC
Please print:
Property Owner: _ CQ�1 Car C�RI"c51-�F�M
Property Owner: (ZESA Fr2v5T t � ��ES} � X �
The undersigned, registered property owners of the above noted property, do hereby authorize
SC -FF ZiKE , of -S1�7 8y1!t�cRS
(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):
40-Y VA- i Ch(Z �X 2-7513
Telephone: ,119-2-
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We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
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Authorized Signature
Date: 5 1 J-2- 19
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Authorized Signature
Date: 5112.Z I °�