Mt. Vernon Church Road

AGENT / LANDOWNER AUTHORIZATION FORM

PROPERTY LEGAL DESCRIPTION:

PARCEL ID: ____0050904_____________________ Deed Bk/Pg: _19405/
1254__________________________

LOT NO. ______________ PLAN NO. _________________

STREET ADDRESS: _____1508 Mt Vernon Church Rd, Raleigh, NC.
27614_______________________________________________________________
____________________________________________________________________________________

Owner(s) Please print: ____George Todd Smith, Melissa D.
Dobbins_____________________________________________________________

Property Owner(s) (signature): ___________________________________________________________
___________________________________________________________

The undersigned, registered property owners of the above noted property, do hereby authorize

David Gillett
________________________________________, of _______Morton Bradbury Real Estate
Group_________________________________
(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):
__________3429 Apache Drive, Raleigh, NC.
27609_________________________________________________________________________

Property Owner Telephone: ____(919) 691-1234, [phone]_________________________

I/We hereby certify the above information submitted in this application is true and accurate to the best of
my/our knowledge.

dotloop signature verification: dtlp.us/5Rph-YZnj-RP7w
_____________________________________ _____________________________________
Owner(s) Signature Authorized Signature

Date: _______________________________ Date: _______________________________
George Todd Smith dotloop verified
09/21/23 9:39 PM EDT
DPXM-N30V-OPSA-2MVS
Melissa D. Dobbins dotloop verified
09/25/23 6:31 PM EDT
GTSA-ZFXQ-FTF6-NN5C David Gillett dotloop verified
09/21/23 3:42 PM EDT
FLC0-92PE-6S0Q-RSNE
dotloop signature verification: dtlp.us/5Rph-YZnj-RP7w