Barron_Agent_Authorization_SIGNED

AGENT AUTHORIZATION FORM
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:
177 Trawler LN, Merritt, NC 28556
Parcel ID:
7501675343000
Property Owner Name(s) — please print:
Property Owner: Frank Barron
Property Owner:
The undersigned, registered property owners of the above noted property, do herebyauthorize
Brian Grigsby/Agent , of
(Contractor/Agent)
AJ Earthworks
(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 Mailing Address (if different than property address above):
Property Owner(s) Telephone: [phone]
We hereby certify that the above information submitted in this application is true and accurate tothe
best of our knowledge.
Authorized Signature Authorized Signature
Z3
Date Date