20211233 Ver 1_Agent Authorization Letter_20210914

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
__________________________________, of ________________________________________
(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: _______________________________
078670672647
__4120 PICARDY DRIVE, _________________________________RALEIGH, NC 27612
JEAN PIERRE DUERI
LOUIS CHERRY ARCHITECTURELOUIS CHERRY