20150034 Ver 1_Agent Authorization Letter_20150112

TOWN OF HOOKERTON AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. N/A PLAN 'NO. 'N/A PARCEL ID: 0623058'.
STREET ADDRESS: 945 HWy 123 North. Hookerton NC. 28538
Please print:
Property Owner: Town of Hookerton
Property Owner:
The undersigned, registered property owners of the;abovemoted property, do hereby authorize
Jason Hales of SEPI Enoineerino and Construction
(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):
227 Main Street, P.O. Box 296, Hookerton NC, 28538
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signa ure
Date:'
Authorized Signature
Date: