20230072 Ver 1_03_Princeton SouthPine_AGENT_AUTHORIZATION_FORM_SCAN_20230112

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. Various PLAN NO. PARCEL ID: Various
STREET ADDRESS: Located around the intersection of South Pine Street and Ballpark Road in
Princeton, North Carolina for the "Princeton South Pine Drainage Improvements" project.
Please print:
Property Owner: Town of Princeton
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Scott Davis
(Contractor / Agent)
of Axiom Environmental, Inc
(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):
503 Dr. Donnie H. Jones Blvd West, Princeton, NC 27569
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
%ice A" &r:vv
Authorized (Sig atur(e�1' q Authorized Signature
Date: G it, l t hit/ Date: