20200941 Ver 1_Agent Authorization_20200721

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 654702867363
STREET ADDRESS: 24524 South Business 52 S., Albemarle, NC 28001
Please print:
Property Owner: City of Albemarle
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Nathan Howell of Three Oaks Engineering
(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):
14q �). S e ccrn fie -e- a C C 2 000 1
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
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Authorize Signature Authorized Signature
Date: lzolll Date: 02/05/2020