20230670 Ver 1_Agent Authorization_20230511

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 8 PLAN NO.
PARCEL ID: 4730401001
STREET ADDRESS: 187 Brer Fox Trail. Troutman NC 28166
Please print:
Property Owner: Stephen Indelicato
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Dean Fisher of Lake Norman Custom Dock & Pile Driving , 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):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Aut"Signature Authorized Signature
Date: 5—1--2 3 Date: