20230715 Ver 1_DEQ_AGENT_AUTHORIZATION_FAIRHAVEN_20230729

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
PARCEL ID: 8597-24-8025-000
STREET ADDRESS: US Hwy 64, Brevard North Carolina 28712
Please print:
Project Applicant: Commonwealth Development Corporation of America
The undersigned, project applicants responsible for development of the above noted property,
do hereby authorize
Melissa Ruiz
of
(Contractor / Agent)
Stantec Consulting Services Inc.
(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.
Project Applicant's Information (if different than property above):
[e-mail]
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorizd Signature UU
Authorized Signatur
Date: 7/19/23 Date: