20151259 Ver 1_More Info Received_20151208

SAMPLE AGENT AUTHORIZATION FORM
DEC - �
PROPERTY LEGAL DESCRIFHON: ®� 20 a
LOT NO. PLAN NO. PARCEL ID. ll G R.wgrER ,�
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STREET ADDRESS: C �`c I
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Property Owner: (� ! (/�r/ �e,, -2%C �`l vil 1'1 L
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Property Owner: S Yr c k e /l n d ✓`fig l �� 3S o,Z
The undersigned, registered property owners of the above noted property, do hereby authorize
of t L7r h a' eel _. of /IAC 514 , F, L
(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:
G-6 T - (r' ( SYC'
We hereby certify the above Information submitted in this application is true and accurate to the
best of our knowledge.
Authoriz i re
ate: e?
Authorized Signature
Date:

Montalvo, Sheri A
From: [e-mail]
Sent: Tuesday, December 08, 2015 4:08 PM
To: Montalvo, Sheri A
Subject: RE: Countryside Estates
Attachments: Authorization form
Sheri,
Please find attached the form you needed me to sign. Let me know if there is anything further information you may
need.
John
From: Montalvo, Sheri A [mailto:[e-mail]]
Sent: Tuesday, December 08, 2015 12:44 PM
To: [e-mail]
Subject: Countryside Estates
Importance: High
John,
We have received the PCN and fee for the above project. With your name signed to page 10 of 10 we will need signed
authorization from the owner for you, the applicant, to apply. I have attached an authorization form for your use. You
can email it back to me at [e-mail] once completed and I can take the project off hold and forward
through the review process.
Thanks
Sker� Mov�taWo
401 & Buffer Permitting Unit - Administrative Assistant
Department of Water Resources
Division of Environmental Quality
919-807-6303 (office)
[e-mail]
512 N. Salisbury St., Ste 942-G1, Raleigh, NC 27604
1617 Mail Serive Center
Raleigh, NC 27699-1617
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