20170257 Ver 1_7 B-5556 Signed Agent Auth Form_20170306

AGENT AUTHORIZATION FORM
PROPER7Y LEGAL DESCRIPTION:
LOT NO. N/A PLAN NO. N/A PARCELID: 0783922203
STREET ADDRESS: Public right-of-way maintained by the City of Raleigh for Lake Dam Road and
located from approximate address 1202 to 1406 and tracks owned by the City of Raleinh on the
parcel identified above at addresses 1320 and 1351 Lake Dam Road.
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
L. Mark Pearson, PE , of Dewberry Engineers Inc.
(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 aIl standard and special conditions attached.
Property Owner's Address (if different than property above):
City of Raleigh, Engineering Services Dept.— Stormwater Management,
127 W. Hargett Street, Suite 800, Raleigh, NC 27602-0590 (P.O. Box 590)
Telephone: [phone]
Email: [e-mail]
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
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Au -ori ed Signature Authorized Signature
Date: �7" �' � i Date: