20180307 Ver 1_Agent Authorization_20180227

SAMPLE AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. See Attachemnt PLAN NO. PARCEL ID:
STREET ADDRESS: See Attachment
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Jason Marshall of GHD, 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 all standard and special conditions attached.
Property Owner's Address (if different than property above):
222 South Church Street, Suite 400, Charlotte, NC 28202
Telephone:
704-342-4913
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
Authorized Signature Authorized Signature
Date: Date: