20230575 Ver 1_Agent Authorization_20230425

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 16 PLAN NO:
STREET ADDRESS;
18132 Nantz Road
Cornelius, NC 28031
Please print:
Property Owner; Troy Herbst
Property Owner:
PARCEL ID: 00105216
The undersigned, registered property owners of the above noted property, do herebyauthorize
DONNA P HRKO , of LANCASTER'S CUSTOM DOCK & LIFT SYSTEMS,
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 Owners Address (if different than property above):
P.O. Box 97137
Las Vegas, NV 89193
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge,
Authorized Sig ature Authorized Signature
1/31/23
Date
Date