20220017 Ver 1_Agent Authorization_20220104

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: N/A _ PLAN NO: PARCEL ID: Pin 2774635019
STREET ADDRESS:
110 Jenjalo Dr. — -___ —----------
Hickorv. NC 28601 -- ---
Please print:
Property Owner: Brian R. Heffron
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Charlie_ Washburn _ , of Marine Construction LLC
(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 Owners Address (if different than property above):
same
Telephone: [phone] _.
We hereby certify the above information submitted in this application is true and accurate tothe
Authd Signa ure
IL o j o- j --
Date