20161199 Ver 2_Agent Authoization Form signed Justin_20180920

AGENT AUTHORIZATION FORM for Section 404-401 Permitting
PROPERTY LEGAL DESCRIPTION: Carvers Creek State Park
LOT NO. PLAN NO. PARCEL ID: 0503-80-5253 Cumberland Co.
STREET ADDRESS: 2505 Long Valley Road Spring Lake, NC 28390
Please print:
Property Owner 1: State of North Carolina,_116 West Jones Street Raleigh NC 27699
Property Owner 2:
The undersigned, registered property owners of the above noted property, do hereby authorize
Gerald Pottern and Rich Mogensen of Moaensen Mitigation Inc (MMI-RJGA)
(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):
North Carolina Division of Parks and Recreation. 121 West Jones Street Raleigh NC 27603
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
/Authorized Signature 1
Authorized Signature 2
Date: Y- /G - 2Glb- Date: