20230536 Ver 1_BL-0036_AGENT_AUTHORIZATION_FORM_Permitting_Signed_20230418

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
STREET ADDRESS: 801 High House Road Cary, NC 27513
Please print:
Property Owner:
Town of Cary
Property owner: ATTN: Todd Milani
The undersigned, registered property owners of the above noted property, do hereby authorize
James Mason/Nancy Oberle of Three Oaks Engineering, Inc
(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):
PO Box 8005 Cary, NC 27512-8005
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
DocuSigned by
DC067BB085F34FB...
Authorized Signature
12/5/2022
Date:
Electronically by:
86A—�0-21r-
Authorized Signature
Date: 12/2/2022
Electronically signed by:
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