20230932 Ver 1_N Buffalo Agent Authorization_20230624

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTIONS:
CITY PROPERTY:
PIN 7864291108 LAKE DANIELBENJAMIN PW
PIN 7854894604 SUNSET HILLS COMPLEX 3398-1136
Please print:
Property Owner: City of Greensboro
The undersigned, registered property owners of the above noted property, do hereby authorize
Cynthia C. Lancaster, PE. , of UB Engineering PC
(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):
City of Greensboro
PO Box 3136
Greensboro, NC 27402
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Aurorized Signature
Date: {Zf Z42-�