20211811 Ver 1_Agent Authorization_20211214

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION. -
LOT NO: 921 PLAN NO;
STREET ADDRESS;
174 Winding Shore Road
Troutman, NC 28166
Please print:
Property Owner: James Lee
Property Owner:
PARCEL ID: 4639690779
The undersigned, registered property owners of the above noted property, do herebyauthorize
Donna P. Hrko , of Lancaster Custom Dock and Lift Systems, Inc.
(Contractor/Agent) (Name of conci,ltinn 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):
2810 Phillippe Parkway
Safety Harbor,, FL 34695
Telephone; 508 28-0582
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge.
Authori Signaturd Authorized Signature
12-10- 1
Date
Date