20201664 Ver 1_Complete Landowner Authorization Form_20201029

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LANDOWNER AUTHORIZATION FORM
PROPERTY LEGAL DESCRITION:
Deed Book: Page:
Parcel ID Number:
County: _'IW 4 i �_ I�
Street Address: hA*Wu, l ). G � QlAX,fi6t yql
Property Owner (please print)
Property Owner (please printe7.
The undersigned, registered property owner(s) of the above property, do hereby authorize
. zxffaL 1";% — of 112x4LraL'1x lw" W",
(Contractor/Agent/Project Manager)i (Name of Contractor) ent Firm/Ageney)2
to take all actions necessary for the evaluation of the property as a potential stream, wetland and/or
riparian buffer mitigation project, including conducting stream and/or wetland determinations and
delineations, as well as issuance and acceptance of any required permit(s) or certification(s). I
agree to allow regulatory agencies, including the NC Division of Water Resources, to visit the
property as part of these environmental reviews.
Property Owners(s) Address: 29 WQQJ J1114 — F� m F9 L1
(if different from above)
(LAI n CID ': 11� ILL 1Ss5�?D
Property Owner Telephone Number:(d -2_ ,fir
Property Owner Telephone NumberzS2, -Y 716-- O&V _
We hereby certify the above information to be true and accurate to the best of our knowledge.
(Property wner Authorized Signa! e) (Date)
(Properly-Own,q Authorized Signature)
-.2gQ0ao
(Date)
'Name of full delivery staff member (full -deliveries) or DMS project manager (design -bid -build).
2Name of company (frill -deliveries) or DMS (design -bid -build).