20240569 Ver 1_Agent Autorization Form.Executed_20240418

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO.
PARCEL ID: 0822354950
STREET ADDRESS: 1219 Broad St., Durham, NC 27705
Please print:
Property Owner:
Property Owner:
State of North Carolina - NCSSM
Robert Allen
The undersigned, registered property owners of the above noted property, do hereby authorize
Grant Livengood, PE
(Contractor / Agent)
of McKim & Creed, 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 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: �`� / 2,i�
Authorized Signature
Date: