20150189 Ver 1_More Info Received_20150218

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AGENT AUTHORIZATION FORM
11 M.-MM-IM1111
PROPERTY LEGAL DESCRIPTION:
PIN: 9587108293 / 9587109014 DEED BOOK: = PAGE NO: 689 / 686
STREET ADDRESS:
Please print:
Property Owner: Carolina Mountain Land Conservancy
Applicant: Kieran Roe
The undersigned, registered property owners of the above noted property, do hereby authorize
S. Grant Ginn, P.E. _, of W01f Creek Engineering,. pilc
(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):
Telephone: [phone]
We hereby certify the above Information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Sign tune
Date:
A z Sin re
Date: ? 17 1