20230609 Ver 1_Agent Authorization_20230428

AGENT AU1 HORIZA"TION FORM
PROPERTY LEGAL DESCRIPTION':
LOT NO: 7 PLAN NO:
STREET ADDRESS:
122 Shady Cove Road
Troutman, NC 28166
2�M
Proper ,Owner: w RanceTillotstin
2ff2-HZ=
PARCEL ID: 4730714925
The undersigned, registered property owners of the above noted property, do herebyauthorize
Donna P. Hrko
of Lancaster Custom Dock and L!"stemis, Inc.
(Contractor/Agent) (Name of consuffing firm)
—Irc-OT'IsTu6ssTirf; Issilanceanci acceptance ot thi2
L
permit or certification! and any and all standard and special conditions attached.
Property Owners Address (if different than property above):
Telephone -
We hereby certify the above information submitted in this application is true and accurate tothe
best of our knowledge,
A4uthord ed &gnature Authorized Signature
3-14-2023
Date
i OUR