20231598 Ver 1_Agent Authorization_20240103

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. 122 PLAN NO. PARCEL ID: 00176224
STREET ADDRESS: 20107 Bascom Ridge Drive.
Cornelius, NC 28031
Please print:
Property Owner: William Gran
Property Owner:
The undersigned, registered property owners of the above noted property, d❑ hereby authorize
Donna P. Hrko
(Contractor / Agent)
Lancaster's Custom pock and Lift Systems, Inc.
of
(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):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signat IlyAuthorized Signature
9/2S/23
Date: Date: