20230855 Ver 1_Agent Authorization_20230615

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. A portion of lot 806 and all of lot 807PLAN NO. PARCEL ID: 657401057754
STREET ADDRESS: 1567 Berry Hill Drive, Norwood, North Carolina 28128
Please print:
Property Owner: Laura Bolduc
Property Owner: Daniel Orlich
The undersigned, registered property owners of the above noted property, do hereby authorize
Alex Ricketts of Anchor Design Marine Construction
(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):
6123 LAKE PROVIDENCE LANE, CHARLOTTE, NC 28277
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: 06/11/2023 Date: 06/11/2023