20190190 Ver 1_AGENT_AUTHORIZATION_FORM_20190328

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO. PLAN NO. PARCEL ID: 0785-38-1692
STREET ADDRESS: _4104 Ebenezer Church Road, Raleigh, NC
Please print:
Property Owner: _Mark P.
Property Owner: _Joanne R. Boone
The undersigned, registered property owners of the above noted property, do hereby authorize
_Rhonda L. Brewington, PE of _Alpha & Omega Group_
(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): _4401 Dewees Court Raleigh, NC
27612
Telephone:
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
M0)6V1V
Authorized nature
Date: _3/Q2/PZ
AlYth Si natuure
Date: 3 !�