20210692 Ver 1_Agent Authorization_20211110

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: n/a PLAN NO: PARCEL ID: 372515644667
STREET ADDRESS:
5080 16th St Dr NE
Hickory, NC 28601
Please print:
Property Owner: John Bragg III
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Charlie Washburn , of Marine Construction LLC
(rnntrartnr/Anent) (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 property above):
16405 McAuley Rd
Huntersville, NC 28078
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge. ©"�
Authorized Signature
Date
1pIgnature