20221750 Ver 1_Roxboro_AGENT_AUTHORIZATION_FORM_Signed_20221213

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT No. PLAN No. PARCEL ID: 9990-01-16-2933.000
STREETADDRESS: off of Edwin Robertson Road, Woodsdale, NC
Please print: Duke Energy
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
James Mason/Nancy Oberle of Three Oaks Engineering
(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):
411 Fayetteville St, Raleigh, NC 27601
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
rl c h a rd wilesDigitally signed Date: 2022.11 2b1y14:10:10 105'00'
Authorized Signature
Date: 11 /21 /2022
EElectronically signed by:
Nancy O be rl e Digitally signed by Nancy
Date: 2022.11.11 12:38:55-05'0 -O5'00'
Authorized Signature
Date: 11 /11 /2022