20220507 Ver 1_Att C Agent Authorization Form-s_20220602

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 134-47 (plat) PLAN NO. PARCEL ID: 0609-55-1146
STREET ADDRESS: 200 Tabernacle Road, Black Mountain NC, 28711
Please print:
Property Owner: Ken Kramer
Property Owner: Givens Highland Farms, LLC
The undersigned, registered property owners of the above noted property, do hereby authorize
Robert Cork , of Anchor QEA of NC, PLLC
(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):
same as above
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Ken Kramer osazouoso3,7o,srz..
Authorized Signature
Authorized Signature
Date: Date: