20190145 Ver 1_4679_001_20190130

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTIONS:
UPSTREAM
LOT N0. 1�2 BLOCK N0. 4264 PaRCE� r�: 5893357356000 ADDRESS: 0 EDGEWATER DR
DOWNSTREAM
�OT ►v0. 004 BLOCK N0. 4264 P,4RCE� ��: 5893450212000 ADDRESS: 0 SPRINGSIDE DR
�OT NO. 005 BLOCK N0. 4264 PARCE� 1�: 5893450111000 ADDRESS: 3211 SPRINGSIDE
DR
NOTE: THE VILLAGE OF CLEMMONS IS OBTAINING EASEMENTS FOR THE PROJECT AREAS ON THESE
PROPERTIES.
Please print:
Property Owner: Village of Clemmons, NC (ROW)
Upstream Property Owner: ]ames E Rhodes and l.eslie G Fry
Downstream Property Owner: Marvin G. Crews (Lot 4) Rene' Davis Brooks �Lot 5)
The undersigned, registered property owners of the above noted property, do hereby authorize
Cxnthia C. Lancaste� PE, of ]EWELL Engineering Consultants� PC
(Contractor / Agent) (Name of consulting firm)
to act on the Village's 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):
Village of Clemmons
Mike Gunnell, Public Works Director/Village Engneer
3800 Dillon Industrial Drive
Clemmons, NC Z7012
Telephone: [phone]
We hereby certify the above information submitted in this application is true and accurate to the best of
our knowledge.
Autho ized Signature Authorized Signature
Date; � � � -3 Date: