HomeMy WebLinkAbout20231446 Ver 1_Old-Panther Landing, LLC Signed Agent Auth_20231020AUTHORIZATION TO ACT AS REPRESENTATIVE FORM
Property Legal Description:
DEED BOOK: -1723— PAGE NO: _ 850
STREET ADRESS:—O-Camellia Mo ock NC 27958
Please Print:
Property Owner: _Panther Landing, LLC, c/o Jen-y Old
Property Owner:
The undersigned property owners of the above noted property, so hereby authorize
Doug Dorman , of Atlantic Environmental Consultants, LLC to,
(Contractor/Agent) (Name of consulting firm)
1. Act on my behalf and take all actions necessary for the processing, issuance and
acceptance of permits and/or certifications and any all standard and special
conditions attached.
2. Enter the property to obtain site information including inspections with regulatory
agencies (Dare County, North Carolina Department of Environmental Quality,
U.S. Army Corps of Engineers, etc.) fbr the purpose of obtaining permits and/or
certifications.
Property Owners Address (if different than property above):
PO Box 505 Mo ock NC 27958
Property Owners Telephone Number: 252-207-3002
We hereby certify that the above information submitted in this application is true and
accurate to the best of our knowledge.
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A thor ed Signature and Titl Authorized Signature and Title
Date: - it - Z-7 Date:
This certification is valid thru (date)