20170297 Ver 1_Agent Authorized_20170313

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID:
STREET ADDRESS: Transmission line extending approximately 28 miles through Warren and Halifax Counties.
Please print: Virginia Electric & Power Company d/b/a Dominion North Carolina Power
Property Owner:
Property Owner:
c/o Ms. Amanda Mayhew
The undersigned, registered property owners of the above noted property, do hereby authorize
Jennifer B. Johnson
(Contractor / Agent)
of Stantec Consulting Services 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):
701 East Cary Street, 12th Floor, Richmond, Virginia 23219
Telephone:
804-771-6145
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
_M !'�.w
AuttPrized Signature"
Date:
Authorized Signature
Date: