20210722 Ver 1_Agent Authorization_20210518

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. ______________ PLAN NO. ____________ PARCEL ID: ________________________
STREET ADDRESS: _____________________________________________________________
_____________________________________________________
Please print:
Property Owner: ________________________________________________________________
Property Owner: ________________________________________________________________
The undersigned, registered property owners of the above noted property, do hereby authorize
__Alexander P. (Sandy) Smith____, of ___Axiom Environmental, Inc.___________________
(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):
_________________________________________________________________
Telephone: _____________________________
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
__________________ __________________ _________________ __________________
Authorized Signature Authorized Signature
Date: _______________________________ Date: _______________________________
NCDOT Rail Project P-5726
NA NA
NCRR ROW, adjacent to
Salisbury Rail Station
215 Depot Street, Salisbury, NC 28144 (adjacent to rail line at
Salisbury Train Station)
NCDOT Rail Division
ATTN: Matthew Potter, PE
NCDOT Rail Division, 1553 Mail Service Center, Raleigh, NC 27699-1553
919-707-4738
5/6/2021