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Catawba County Permit Center Authorization Form
P.O. Box 399
Newton, NC 28658
Telephone: (828)465-8399 Fax: (828)'465-8962
FULL License Number: (i.e. LIL-12345) M60&
License holders name:/='G W>t 6 Pn;k-;n
Business / Owner Name: /-A ccx.,�c &-6w t6
I ,--r i c T ,Q T 6\ h, wscertify that the following individuals are authorized to sign for a
(Print Name)
permits for this organization where allowed in the NC Licensing laws.
Name:
Signature-
Name: .v,Cl lete 64.'I'A
Signature: ZA�4— 'jt�5t�Name:
Signature:
License Holders Signature, c " "G 'A
This form will in no way relieve the signor of any legal obligations concerning the signing of
documentation as defined in the North Carolina General Statutes or the North Carolina Licensing laws,
Updated!4/10/09 a Gi/BLD/PERMCTR/FORMS