20230354 Ver 1_City of Greensboro_Knox_BethelChurchRd_AGENT_AUTHORIZATION_FORM_Flat_20230303

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
PARCEL ID: Multiple
STREET ADDRESS: From SR 2752 (Bethel Church Road) at Peeden Drive
to SR 2814 (Knox Road) at US 70 (Burlington Road), near Gibsonville/McLeansville
Please print: City of Greensboro, ATTN: Shane Messer
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Nathan Howell /James Masonof
(Contractor / Agent)
Three Oaks Engineering
(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):
City of Greensboro, Water Resources Dept., 2602 S. Elm -Eugene St., Greensboro, NC 27406
Telephone:
[phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
shane messer =7
Authorized Signature
Date: 2-22-22
Electronically signed by- Electronically signed by:
Authorized Signature
Date: 12/17/2021