20231019 Ver 1_Agent Authorization_20230724

AGENT AUTHORIZATION FORD
Please note that multiple forms may be necessary if there are more than two owners of the property.
PROPERTY LEGAL DESCRIPTION:
STREET ADDRESS OF EXISTING HOME or LATITUDE/LONGITUDE OF NEW CONSTRUCTION:
111 Lakeside Loop, Hickory, NC 28601
35.811 /-81.332
Parcel ID: 0005007
Property Owner Names) — please print:
Property Owner: Grassy Farms LLC
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Charlie Washburn
(Contractor/Agent)
,of Marine Construction LLC
(Name of company)
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 Mauling Address (if different than property address above):
PO Box 6400, Hickory, NC 28603
PO Box 6400, Hickory, NC 28603
Property Owner(s) Telephone: [phone]
We hereby certify that the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorize ignature Authorized Signature
071-lql a6a3 07- 17- 23
Date Date