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Please note that multiple forms may be necessary if there are more than two owners of the property.
PROPERTY LEGAL DESCRIPTION:
STREET ADDRESS OF EXISTING HOME or LATITUDE/LONGITUDE OF NEW CONSTRUCTION:
104 Brownstone Drive
Moorseville, NC 28117
Parcel ID: 4625773135
Property Owner Name(s) — please print:
Property Owner: William B Haas
Property Owner: Denise Ann Haas
The undersigned, registered property owners of the above noted property, do herebyauthorize
Tina Little , of Little's Lake Permit Services LLC
(Contractor/Agent) (Name of company)
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.
Only for shoreline Stabilization permits
Property Owners Mailing Address (if different than property address above):
Property Owner(s) Telephone:
919-357-2128
We hereby certify that the above information submitted in this application is true and accurate to the
,r best of our knowledge.
Authorized Si nature Authorized Signature
Date Date