Agent Authorization Form.pdf

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT N0. 2 PLAN N0. N/A PARCEL ID: 4619-01-49-5147
STREET ADDRESS: 1383 Langdon Rd., Sherrills Ford, NC 28673
Please print:
Property Owner:
Property Owner.
The undersigned, registered property owners of the above noted property, do hereby authorize
N/A Of N/A
(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):
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature
Date: 1 / 17/24
Authorized Signature
Date: