20231235 Ver 2_Agent Authorization_20240103

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO: 55 & Adjacent Lot PLAN NO:
STREET ADDRESS:
8472 Nolley Lane and Adjacent Lot
Sherrills Ford, NC 28673
Please print:
PARCEL ID: 461601365137 &
461601364102
PropertV Owner: Hastings Wood Family Living Trust David Wood Trustee
Property Owner;
The undersigned, registered property owners of the above noted property, do herebyauthorize
Donna P. Hrko
(Contractor/Agent)
of Lancaster Custom Dock and Lift Systems, 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.
Property Owners Address (if different than property above):
930 Green Tree Drive
Charlotte, NC 28211
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate tothe
best of our �knowledge.
Authorized Signature Authorized Signature
6-1-2023
Date
Date