20181161 Ver 1_Agent Authorization_20180820

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. ______________ PLAN NO. ____________ PARCEL ID: ________________________
STREET ADDRESS: _____________________________________________________________
_____________________________________________________
Please print:
Property Owner: ________________________________________________________________
Property Owner: ________________________________________________________________
The undersigned, registered property owners of the above noted property, do hereby authorize
__________________________________, of ________________________________________
(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):
_________________________________________________________________
Telephone: _____________________________
I/We hereby certify the above information submitted in this application is true and accurate to
the best of my/our knowledge.
__________________ __________________ _________________ __________________
Authorized Signature Authorized Signature
Date: _______________________________ Date: _______________________________
251 Charlotte Highway Asheville, NC 28803
9667-82-5736; 9667-82-5958;
9667-82-6189; 9667-82-9630;
9667-82-9483
Equinox Environmental Consultation & Design, Inc.Owen Carson