20211482 Ver 1_Agent Authorization_20211011

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: 444 PLAN NO:
STREET ADDRESS:
104 Brownstone Drive
Mooresville, NC 28117
Please print:
Property Owner: William Haas
Property Owner:
PARCEL ID: 4625-77-3135
The undersigned, registered property owners of the above noted property, do herebyauthorize
Donna P. Hrko
(Contractor/Agent)
of Lancaster's Custom Dock and Lift Systems, Inc.
(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 Owners Address (if different than properly above):
4416 Monroe Road, Suite C
Charlotte, NC 28205
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge.
Authorized Signature Authorized Signature
10-4-2021
Date Date