20220139 Ver 1_AGENT AUTHORIZATION FORM_20220203

dotloop signature verification: dtlp.us/an2g-dHAX-wTC5
AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
PARCEL ID: 2692828741 Deed Bk/Pg: 1937/492
LOT NO. PLAN NO.
STREET ADDRESS: Salem Church Rd
Owner(s) Please print: Michael Privott
Property Owner (signature):
Maryclair Privott
dotloop verified
02/02/22 10:55 AM
EST
JIBX-GS8F-D5FY-KDUI
Property Owner (signature):_/eaegfi,P
dotloop verified
02/02/22 11:09 AM EST
MWF3-A3X8-MPYE-CXXX
The undersigned, registered property owners of the above noted property, do hereby authorize
Adam McIntyre f of _Water & Land Solutions, 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 Owner's Address (if different than property above):
_PO Box 1767, Mooresville, NC 28115
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
dotloop verified
02/02/22 10:55 AM EST
QY4R-DBOY-JS9N-GQM5
Authorized Signature
dotloop verified
02/02/22 11:09 AM EST
CW W E-IVCR-DYQ L-BLTA
Authorized Signature
Date: 02/02/2022 Date: 02/02/2022